Cornerstone Church of Ione
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- Joleen Gardner
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1 Cornerstone Church of Ione H I G H S C H O O L 2018 January 19th-21st T-Shirt Size: Meet at Cornerstone Church at 5:00pm on January 19 th We will return to Cornerstone Church January 21 st at 2pm COST: $99 if money and registration is turned in by December 31st / $120 after that Bring money for dinner on the 19 th. We will be stopping on our way to camp. Packing list and info sheet will be on the church website and handed out to students on Sundays I give permission for my child to attend and participate in this event sponsored and endorsed by the Student Ministry department of Cornerstone Church of Ione. This includes permission to travel to and from the event if applicable and authorization for any necessary medical treatment. I hereby release and agree to hold harmless Cornerstone Church of Ione together with its agents and employees from all actions, causes, damages, claims, or demands which I, my heirs, executors, administrators or assigns may have against Cornerstone Church of Ione for any and all personal injuries, loss, or damage, known or unknown, which my child may incur by participating in the above activities or outings. I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with knowledge of its significance. The undersigned further agree to assume full financial responsibility for any and all charges incurred, specifically including ambulance, physician, hospital, and medication expenses. In the event of injury to the participant, I understand that the participant s own medical insurance is primary. Please complete everything in this box. Please initial here if you have completed and signed the Cornerstone Church of Ione Annual Medical Release form and permission slip as well (required in addition to this form). My child has my permission to go sledding. My child has my permission to go snow tubing. My child has permission to be transported by volunteer Cornerstone Youth staff. Students name: age: Signature of Legal guardian: date:
2 2018 Cornerstone Church Medical Release & Permission Form Today s Date: Name: LAST FIRST MIDDLE Age Birthday Year in school Male Female Parent Address City State Zip Students Primary Phone # Secondary Phone # Medical insurance company Policy number Insured Billing Address Mother s name Phone: Home Cell Father s name Phone: Home Cell Emergency contact Phone: Home Cell Physician Office phone Dentist Office phone Medical History If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken. Check the following areas of concern for this student. If necessary, add another page with details: 1. For your child s safety and our knowledge, is your child a good swimmer fair swimmer non-swimmer 2. Does your child have allergies to medications food insect bites other If so, please list all known allergies: 3. Please list all medications your child is currently taking: 4. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: asthma epilepsy/seizure disorder heart trouble diabetes physical handicap other 5. Date of last tetanus shot: 6. Does your child wear glasses contact lenses 7. Please list and explain any major illnesses the child experienced during the last year: Should this child s activities be restricted for any reason? Please explain:
3 For your information, we expect each student to conform to these rules of conduct No possession or use of alcohol, drugs, or tobacco No students can drive No fighting, weapons, fireworks, lighters, or explosives No offensive or immodest clothing No boys in girls sleeping quarters and no girls in boys sleeping quarters Participation with the group is expected Respect property, one another, staff, adult leaders, and comply with event schedules rev. 06/12 Students who fail to comply with these expectations may be sent home at their parents expense. I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in Cornerstone activities. I agree to abide by the stated personal limitations and code of conduct. Student signature: Date: By signing this form, you agree to assume and accept all risks and hazards inherent in church-related travel, ministry, social and sport activities including transportation to and from activities. You also agree that you will not hold Cornerstone Church or its employees or volunteer assistants liable for damages, losses or injuries to the person named on this form. You understand that this form and your signature are for both medical and liability release. (students name) has my permission to attend all activities sponsored by Cornerstone Church of Ione from January 1, 2018 to December 31, This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. (Parent initials acknowledgement) Photo and Video Release I understand that the activities and events sponsored by Cornerstone Church of Ione are considered public and may be photographed, and that these photos may be presented in various church-sponsored media, including but not limited to: photos, videos, slide presentations, PowerPoint presentations, newsletters, bulletins and/or bulletin inserts, brochures, handbooks, programs, and Internet Web pages. I hereby remise, release and forever discharge Cornerstone Church of Ione from any liability for any injury or action against the above-named minor resulting from the use of such photos, video, or other image in any medium utilized. This release includes that Cornerstone Church of Ione will not be responsible for other users production, display, distribution, or modification of the minors images in any manner, nor will Cornerstone Church of Ione be responsible for defamation, misrepresentation, or criminal acts as a result of unauthorized use of Cornerstone Church of Ione images by third parties. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Children s Ministries staff member or Lead Volunteer. Signature of Mother or Legal Guardian Date Signature of Father or Legal Guardian Date Cornerstone Church of Ione Return this form to: PO Box 304 Ione CA Received on:
4 JENNESS PARK CAMPER INFORMATION FORM (To be completed by ALL CAMPERS, if Camper is under age of 18 document must be signed by parent or guardian; both sides must be completed in full) Group Name: Dates of Camp: / / - / / Contact Information: Name of Camper: Age: Date of Birth: / / Sex (check): Male Female Last First Parent/Guardian of Camper: Address: Last First ( ) ( ) Street Address City State Zip Home Phone Cell Phone Emergency Contact: ( ) ( ) ( ) Home Phone Cell Phone Work Phone Family Doctor: ( ) Insurance Company: Policy #: Office Phone JENNESS PARK S INSURANCE IS ONLY SECONDARY INSURANCE, AND BEGINS WHERE CAMPER S HEALTH AND ACCIDENT INSURANCE POLICY TERMINATES, AND IS ONLY VALID WHEN OTHER INSURANCE HAS BEEN EXTENDED TO ITS LIMITS AND DEDUCTIBLE(S) PAID. Health History: Does the Camper have any physical, mental or other medical conditions and restrictions? If so, please explain: Does the Camper have any known allergies to food, medication, insect bites or other allergens? If so, please explain: Date of Last Tetanus Shot: / / If Camper is under the age of 18, I, the undersigned parent or legal guardian, give Jenness Park permission to administer the following medication (or its generic equivalent) to Camper (check all that apply): Tylenol Ibuprofen Asprin Benadryl Pepto Bismol Neosporin Sudafed Camper is responsible for bringing to Camp all regularly required medications and dosages: Please list all medications brought to Camp: Name of Medication: Frequency and Dosage Schedule: MEDICAL RELEASE: If I, the undersigned, am injured as a Camper or cannot be reached in an emergency involving my child during the camp dates show above, I hereby authorized Jenness Park to give consent and agree, on my behalf, to pay for any emergency medical or dental care for me or my child under Family Code section 6910, as the case may be. This authorization includes the authority to give consent and agree, on my behalf, to pay for any injection, anesthesia, surgery or orthodontic care deemed necessary by, and to be rendered under the general or special supervision of a qualified physician, surgeon or dentist. I also authorize the health supervisor on duty at Jenness Park to administer medical aid as required for illness of or injury to me or my child. Signature of Adult Camper or Parent/Legal Guardian of Minor Camper Printed Name Date Signature of Witness Printed Name Date Page 1 of 2
5 JENNESS PARK ASSUMPTION OF RISK AND LIABILITY RELEASE TO BE COMPLETED BY THE ADULT CAMPER OR THE PARENT OR LEGAL GUARDIAN OF ANY CAMPER UNDER THE AGE OF Voluntary Participation/Permission. I, the undersigned, am (check one) a Camper of at least 18 years of age or the parent or legal guardian of the minor Camper named on the preceding page. I acknowledge that I have voluntarily applied, or authorized my child to participate in the Camp Activities that occur at, on or around Jenness Park. I understand that these Camp Activities include, but are not limited to, swimming in the lake, boating, adventure recreation, archery, paintball, go karts, strenuous competition games, and other camp activities and exercises. I understand that I minimize my risk of injury as I AGREE TO FULLY COMPLY WITH ALL RULES AND DIRECTION BY STAFF FOR ALL CAMP ACTIVITIES. I AGREE TO WITHDRAW FROM ANY CAMP ACTIVITY SHOULD I BECOME AWARE OF ANY UNUSUAL HAZARD WHICH ENDANGERS THE SAFETY OF ANY PARTICIPANT, AND TO REPORT IT IMMEDIATELY TO CAMP STAFF. I HAVE FULLY DISCLOSED ANY PHYSICAL OR MENTAL CONDITION THAT MAY LIMIT MY PARTICIPATION AND I WILL NOT PARTICIPATE IN ANY CAMP ACTIVITIES AGAINST MEDICAL ADVICE. I accept full responsibility for any injury or accident to me or my child, as the case may be, that may occur as a result of my participation or my child s participation in any of the Camp Activities or attendance at Jenness Park. 2. Assumption of Risk. I AM AWARE THAT THE CAMP ACTIVITIES ARE HAZARDOUS ACTIVITIES. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES OR PERMITTING MY CHILD TO PARTICIPATE IN THESE ACTIVITIES, AS THE CASE MAY BE, WITH KNOWLEDGE OF THE DANGER INVOLVED. I FURTHER HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH TO ME OR MY CHILD, AS THE CASE MAY BE, AND VERIFY THIS STATEMENT BY PLACING MY INITIALS HERE: 3. Release. As consideration for me or my child being permitted by Jenness Park and the California Southern Baptist Convention to participate in the Camp Activities and use related facilities, I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make a claim against, sue, or attach the property of Jenness Park or the California Southern Baptist Convention, or any of their respective employees, directors, officers, or agents, on account of injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, or contractor of Jenness Park or the California Southern Baptist Convention as a result of my participation in any of the Camp Activities. 4. Knowing and Voluntary Execution. I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND JENNESS PARK AND THE CALIFORNIA SOUTHERN BAPTIST CONVENTION, AND SIGN IT OF MY OWN FREE WILL. 5. Use of Media. I acknowledge and agree that for promotional or marketing purposes, Jenness Park may use any audio, video, and/or photography of guests or Campers, which may include me or my child, participating in the Camp Activities or otherwise present at Jenness Park. 6. Arbitration. I hereby agree to submit any dispute arising from participation in Camp Activities to binding arbitration. Submission shall be unlimited. There shall be a three-member arbitration panel, consisting of two party-appointed arbitrators (one arbitrator appointed by each party) and one neutral arbitrator to be chosen by the party-appointed arbitrators. The neutral arbitrator shall be an officer or director of any Christian Camp & Conference Association (CCCA) member camp. Should the two party-appointed arbitrators fail to agree on the neutral arbitrator, the neutral arbitrator shall be appointed by the California Eastern District Court, Fresno, CA using the criteria set forth herein. Each party shall pay its own costs, including its party-appointed arbitrator, and share equally the costs of the neutral arbitrator. The arbitration proceedings will take place in Fresno, CA and shall be governed by the Federal Rules of Evidence. The panel shall establish a reasonable and appropriate discovery schedule to expeditiously resolve the dispute. 7. Indemnity. Should Jenness Park and/or the California Southern Baptist Convention, or anyone acting on their behalf, incur any loss, liability, damages or attorneys fees and costs to enforce this Release, I agree to indemnify and hold Jenness Park and the California Southern Baptist Convention harmless for any such loss, liability, damages, or attorneys fees and costs. BY SIGNING THIS RELEASE, I ACKNOWLEDGE THAT IF THERE ARE ANY INJURIES OR PROPERTY DAMAGE DURING MY OR MY CHILD S PARTICIPATION IN THESE ACTIVITIES, I AND/OR MY CHILD MAY BE FOUND BY A COURT OF LAW TO HAVE WAIVED ANY RIGHT TO MAINTAIN A LAWSUIT AGAINST JENNESS PARK OR THE CALIFORNIA SOUTHERN BAPTIST CONVENTION ON THE BASIS OF ANY CLAIM WHICH HAS BEEN RELEASED HEREIN. I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT, HAVE READ AND UNDERSTOOD IT, AND AGREE TO BE BOUND BY ITS TERMS. If you would not like to receive Jenness Park newsletter and other printed materials, please check the box. Signature of Adult Camper or Parent/Legal Guardian of Minor Camper Printed Name Date DECLARATION OF WITNESS I certify that the signatory set forth above acknowledged in my presence that he/she read and fully understood the meaning and consequences of the foregoing ASSUMPTION OF RISK AND LIABILITY RELEASE, and signed it in my presence. Signature of Witness Printed Name Date Page 2 of 2 DMS: _1
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