hsc release forms
(check one) o All High School Events o Specific Event Only __________________ Date (if applicable): ______________ 1st Student Name 2nd Student Name 3rd Student Name 4th Student Name Grade ______ Grade ______ Grade ______ Grade ______ ____________________________ ____________________________ ____________________________ ____________________________ Age Age Age Age _____ Birthday ___________________ _____ Birthday ___________________ _____ Birthday ___________________ _____ Birthday ___________________ Home Phone ___________________________________________________________________________________ Cell Phone _____________________________________________________________________________________ Emergency Contact _____________________________________________________________________________ Emergency Number _____________________________________________________________________________ Address ________________________________________________________________________________________ City _____________________________________________________ Zip _________________________________ I authorize the participation of my child in all activity sponsored by Five14 Church. I am aware of the special dangers and risks inherent in participating in the activity including physical injury, death, or other consequences arising or resulting from the activity. I agree to accept responsibilities. I further agree to advise activity planners and sponsors of any physical or mental limitations my child may have. I agree to be fully responsible for my own property and equipment related to this activity. In consideration of and part of a right to participate in this activity, I hereby release and indemnify Five14 Church and event sponsors of any and all liability, claims and causes of action arising out of or in any way connected with my participation in this activity. I also agree that, in the event medical treatment is required, medical personnel may provide care necessary, including hospitalization, anesthesia, injection, or surgery for my child’s wellbeing. I agree to accept responsibility for any medical costs that may result. I hereby agree to indemnify and hold harmless Five14 Church, and its officers, employees, and volunteer staff from any liability. Participant Name: _______________________________________________________________________________ Participant Signature: (parent/guardian if minor or child) _____________________________________________ Date: __________________________________________________________________________________________ Name: ______________________________________________________________ First Middle Last ❒ Male ❒ Female Birth date: ______________ Camp Attending: ❒ HSC Beach ❒ HSC Mountain __________________________________________________________________________________________ Street address City State Zip First Parent/legal guardian/spouse to be contacted in case of illness or injury: Name: _______________________________________________________ Phone number: (____) ____-______ Relationship to attendee: ____________________ Home address: __________________________________________________________________________________________ (if different from above) Street address City State Zip Diet, Nutrition: ❒ This attendee eats a vegetarian diet. ❒ This attendee eats a gluten free diet. (Please describe below) Middle Allergies: ❒ No known allergies. ❒ Attendee is allergic to: ❒ Food ❒ Medicine (If attendee has allergies, please describe what the camper is allergic to and the reaction seen.) ❒ This attendee eats a peanut free diet. ❒ This attendee has special food needs. Last Authorization and Indemnification Restrictions Any restrictions and limitations of my student are solely the responsibility of the church my student is attending High School Camp with. I hereby acknowledge and agree that High School Camp is not responsible for any restrictions or limitations of my student’s activities. Photo Release I hereby grant to High School Camp the right to use, reproduce, and/or distribute photographs, films, videotapes, and/or sound recordings of the my student, without compensation or approval rights, for use in materials promoting the activities of High School Camp. Attendee signature _________________________________________________ (if over 18 years of age) Signature of Parent/Legal Guardian _________________________________________________ © 2014 The reThink Group, Inc. 2015 High School Camp Release Form Date ______________ Date ______________ Rev. 11/2014 Church Name: ________________________________ Acknowledgement of Inherent Risk I acknowledge and understand there are inherent risks associated with many camp activities. I assume the risk associated therewith, whether known or unknown to me at this time. I hereby release High School Camp, including its employees, agents, volunteers, and trustees, from all claims, liability, and responsibility for physical injury, including death or illness, and loss of personal property while at camp. This release is binding upon all claims that may be brought by my student’s family, estate, heirs, personal representative(s), or assigns. Name: ______________________________________________________ Attendee Home address: Why Here: Three water parks. Ten indoor and outdoor thrill rides. A 10,000-‐foot wave pool. A 19,000-‐gallon surfing experience. HSC MOUNTAIN promises to present a different adventure every day. The deluxe, mountain-‐ resort accommodations make for a memorable week that is sure to bring small groups closer together. With a backdrop provided by the Blue Ridge Mountains, students will be inspired to encounter God in a whole new way. The HSC team is thrilled to welcome you to HSC MOUNTAIN in Pigeon Forge, TN. Dates and Location: July 13 – 17th 2014 Wilderness at the Smokies Pigeon Forge, TN www.highschoolcamp.com Accommodations: We are staying at the Wilderness at the Smokies located at 1424 Old Knoxville Highway, Sevierville, TN 37876. There are two resort hotel buildings on the property. They all have a luxury mountain/log-‐ cabin feel. Most rooms sleep 6 (a bunk and two queens or something similar). For more information go to http://www.wildernessatthesmokies.com Food In addition to the three meals provided daily, there is a coffee shop, a deli, a snack bar, and a restaurant on the property. Make sure you bring an average of $50 for extra spending money. Fun We know that a boring camp means nobody wins. That’s why the HSC team is made up of the craziest, most creative, most wildly inventive people we can find. From a camp host who will keep you ROTFLing to competitions that are all-‐out war, this will be the most FUN event of your student’s summer. Free time At HSC Mountain there are indoor and outdoor water parks. While we want to offer students some free time to enjoy the great amenities of each location, we also realize that too much of a good thing isn’t such a good thing. So, there will not be long stretches of free time every day. Some days will include a structured, team-‐building recreation time as well. What’s Next? Complete the following things to reserve your spot today! • Five14 Church Permission Slip • High School Camp Consent Form • Minimum $50 (non-‐refundable) Deposit Give these items to Caylee Whipple on a Sunday morning at Five14, or drop them off to the church offices (97 E Main Street, New Albany), or mail them to P.O. Box 361 New Albany, 43054. Email caylee@five14church.com with any questions. Cost is $450 total including a $50 deposit (non-‐refundable) DUE by March 15th, to hold your spot. All monies are due by May 17th, 2015. We leave Monday, July 13th at 8 AM from the Five14 Church offices. • Pack one suitcase & feel free to bring a backpack and pillow. • Don’t forget to bring money for travel meals (average $50 cash for three fast food meals-‐ snacks).`
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