2025 Youth Camp Parental Consent

Participant's Full Name*

First NameLast Name

Participant's Birth Date*

Date

Participant Cell Number

I understand that the cost of camp is $150. All participants must attend from Monday - Friday.*

I agree

Parent/Guardian Full Name*

First NameLast Name

Cell Number*

Please enter a valid phone number.

Work Phone

Parent Email*

example@example.com

2nd Parent/Guardian Full Name

First NameLast Name

Cell Number

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Additional Info

0/90

Medical Insurance Company*

Insurance Policy Number*

Any food, medical, or environmental allergies?*

List any Medical Problems (asthma, seizures, headaches):*

Significant Medical History (surgery, injuries, serious illness)*

Is any medication required?*

YesNo

If yes, list any medications taken regularly and directions:

Blood type:

May your child be given the following medicine? Select in agreement

TylenolIbuprofen

AUTHORIZATION FOR MEDICAL TREATMENT of MINOR

I am the parent or legal guardian of PARTICIPANT {participantsFull} named above (hereinafter "my child") date of birth {participantsBirth}. My child is attending and participating in activities at CACHUMA LAKE. (hereinafter "this camp," "church," "school," etc.) located at: 1 Lakeview Dr., Santa Barbara, CA 93105 beginning on the day of June 23, 2025 - June 27, 2025.

I hereby authorize the CAMP DIRECTOR Pastor Luis Parada and YOUTH LEADER Ronnie Reynoso and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child.

I further authorize the CAMP DIRECTOR and YOUTH LEADER and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP to receive physical custody of my child, under Section 1283 (a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the CAMP DIRECTOR and his/her officers, agents, servants, or employees that are 18 years of age or older who supervise the activities at this CAMP.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

AUTHORIZATION FOR MEDICAL TREATMENT (AGE 18 AND OLDER)

I, {participantsFull}, who was born on, {participantsBirth}, am attending and participating in activities at CACHUMA LAKE RECREATION CENTER. (hereinafter "this camp," "church," "school," etc.) located at: 2225 Highway 154, Santa Barbara, CA 93105 in the County of Santa Barbara, beginning on the day of June 23, 2025 - June 27, 2025.

I hereby authorize the CAMP DIRECTOR Pastor Luis Parada and YOUTH LEADERS Ronnie Reynoso and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child.

I further authorize the CAMP DIRECTOR and YOUTH LEADERS and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP to receive physical custody of my child, under Section 1283 (a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the CAMP DIRECTOR and his/her officers, agents, servants, or employees that are 18 years of age or older who supervise the activities at this CAMP.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

Please Print Name of Parent/Guardian and sign below for medical authorization - If you are a participant that is an adult (18 years of age and older) you may print your name and sign your name below in agreement.*

First NameLast Name

Signature for authorization for medical treatment*

If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.

Emergency Contact #1 Name*

First NameLast Name

Relationship*

E-mail*

example@example.com

Cell Phone Number*

RELEASE, WAIVER, AND INDEMINITY AGREEMENT OF MINOR

IS THE INTENTION OF the undersigned PARENT OR GUARDIAN {parentguardianFull95} OF {participantsFull} BY THIS AGREEMENT TO EXEMPT AND RELIEVE BIBLE BAPTIST CHURCH OF LONG BEACH AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF {participantsFull} CAUSED BY ANY ACT OF NEGLIGENCE OF BIBLE BAPTIST CHURCH OF LONG BEACH AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES.

For and in consideration of permitting {participantsFull} to observe, or use any facility or equipment of BIBLE BAPTIST CHURCH OF LONG BEACH or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: CACHUMA LAKE RECREATION AREA in the city of Santa Barbara, County of Santa Barbara, and State of California, beginning on the day of June 23, 2025 - June 27, 2025. I the undersigned parent and/or guardian of {participantsFull}: hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to {participantsFull} as a result of {participantsFull} observing or using facilities or equipment of BIBLE BAPTIST CHURCH OF LONG BEACH or engaging in or receiving instructions in any activities or related transportation SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue.

The undersigned parent or guardian of {participantsFull} for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against BIBLE BAPTIST CHURCH OF LONG BEACH or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless BIBLE BAPTIST CHURCH OF LONG BEACH and its officers, agents, servants, or employees from any and all claims or causes of action by {participantsFull} or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of {participantsFull} present any claim against BIBLE BAPTIST CHURCH OF LONG BEACH and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act ofnegligence by BIBLE BAPTIST CHURCH OF LONG BEACH and said persons.

The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Indemnity and Release Form (Age 18 and older)

I, the undersigned, {participantsFull} wish to voluntarily participate in the Youth Camp at Cachuma Lake Recreation Center.

In consideration for being permitted to participate in the Youth Camp at Cachuma Lake Recreation Center, in the city of Santa Barbara, the state of California, and country of USA, beginning the 23rd day of June, 2025 - 27th of June, 2025, I, the undersigned, {participantsFull}, fully recognizing the dangers and hazards inherent in the Youth Camp, and any related transportation, including personal injury, property damage, or wrongful death, as well as the unknown dangers and hazards which may arise in the course of my participation in the Youth Camp do hereby voluntarily:

Agree, for myself, my heirs and my personal representative, to defend, hold harmless, indemnify, release and forever discharge, to the broadest extent allowed by law, BIBLE BAPTIST CHURCH OF LONG BEACH, its trustees, officers, employees, agents, insurers, successors, assigns, from and against any and all claims, demands, actions, or causes of action on account of any damage to real or personal property or any personal injury or death that may result from my participation in the above Youth Camp.

I have read this release, I understand it fully, I understand that it is legally binding, and I understand that, among other things, I am agreeing to indemnify BIBLE BAPTIST CHURCH OF LONG BEACH, for injuries, damages or losses I may cause and giving up rights to sue BIBLE BAPTIST CHURCH OF LONG BEACH for injuries, damages or losses I may incur.

Print Name of Parent/Guardian of Minor and Sign in agreement to Release/Waiver - Attendees/Adults over 18 years of age may add your own name and sign *

First NameLast Name

Signature of Release/Waiver*

The child named above is in good health and has no physical or medical limitations that would prohibit your child from participating in the meals, activities, church services, and any other gatherings. Parents/guardians should specify allergies and medical problems in section above.

Participants will be transported from Bible Baptist Church via school bus, shuttle bus, and personal automobiles of youth leaders to Cachuma Lake.

Drop Off (Bible Baptist Church) - Monday, June 23, 6:00 AM

Pick Up (Bible Baptist Church) - Friday, June 27, 6:00 PM

I understand that participants may not take their own car and will need to travel with the group in the bus.*

I agree

I understand that participants must bring their luggage and camping supplies on Sunday to get loaded in the Uhaul truck. No coolers are allowed due to space.*

I agree

I hereby attest that I am (we are) the legal parentguardian(s) of the above-named child and hereby consent to the child's participation in the activities described above. I understand that activities of the kind described above may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in those activities.

I/We understand that Bible Baptist Church of Long Beach, does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.

I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions.*

I agree

Date*

Date

Print Name of Parent / Guardian and sign below in agreement. If you are an adult of the age 18 and older please add your name and sign in agreement.*

First NameLast Name

Signature*

Youth Camp 2025 - Bible Baptist Church

General Information

Parent/Guardian Information

Medical Information

Authorization for Medical Treatment

Emergency Contacts (if parent/guardian cannot be reached)

Release and Liability

Requirements

Transportation

Consent / Permission to Participate

Insurance

PLEASE CLICK AGREE AND SIGN BELOW IN AGREEMENT