Tubing - Zipline - Friends Speaker - Snow - Games

Worship

2015 Winter Camp Feb 27-Mar 1

(forms due ASAP)

Buck Creek Camp $119

(scholarships available)

“be greater”

payment accepted online - forms online - bethanystudents.com

Bethany Baptist Church !!Consent for Medical Treatment; Hold Harmless for Travel

Winter Retreat - February 27-March 1, 2015; Buck Creek Camp

Note to Parent/Guardian/Guest: Bethany Baptist Church wants this experience to be a safe and healthy one. However, in the event of an accident or illness, it is important that we have the following information:

1. Medical history 2. Medical insurance information 3. Consent for medical treatment !

1. Attendee: _________________________________________ Birth date:______/______/_________ 2. Whereas (my child) _____________________________________________, wishes to attend a trip with Bethany Baptist Church student ministries group which will be traveling to and staying near Mt Baker, Wa, and WHEREAS, certain circumstances may occur resulting in (my child’s) need for medical/dental care and treatment, and further resulting in my inability to personally give consent for such care and treatment; THEREFORE, in consideration of permission from Bethany Baptist Church for (my child/ myself) to participate in said trip, 4. I, ________________________________________________, being of legal age, authorize Bethany Baptist Church, or any designated agent of Bethany Baptist Church, to act on (my child’s/my) behalf should I be unable to do so and to consent to all medical/dental care and treatment, including but not limited to diagnostic test, x-ray, examination, anesthesia, surgery, or other procedures which Bethany Baptist Church deems necessary for (my child’s/my) medical well-being for the duration of the trip. This consent is given in advance of any specific diagnosis, treatment, surgery, or hospital care required and to the administration of any over the counter medications including but not limited to Tylenol, Advil, allergy medications, and is given to provide authorization and specific, consent for medical/dental treatment and care in (my child’s/my) behalf. Any consent by Bethany Baptist Church shall have the same force and effect as if I had personally given the consent. 5. I certify I have personal health insurance, including foreign countries, with no territorial limitation, for the providing of medical services to (my child/me) which will provide coverage for (my child/me) during the duration of said trip. I understand that Bethany Baptist Church provides no health plan. ! Insurance Company ____________________________________________________ Policy # ______________________________________________________________ Insurance Company Phone Number ________________________________________ !!

I hereby release Bethany Baptist Church, it’s agents, servants, employees, and assign for any and all damages, liabilities or costs resulting from the authorizing of medical treatment on (my child’s/my) behalf under the terms of this consent. I further hold Bethany Baptist Church harmless and agree to indemnify Bethany Baptist Church of any and all costs, damages, or expenses incurred by Bethany Baptist Church as a result of any claim or action filed by any party alleging damages incurred as a result of any medical treatment provided or authorization for treatment provided. I understand that this release and indemnification releases treatment for the conduct of Bethany Baptist Church and its agents, servants, employees, or assigns even if such conduct is negligent !!

!Parent or Guardian Information (for applicant’s under 18)

Name ________________________________________________ Phone # _______________________ Address ______________________________________________ email ____________________ City ______________________________ State ________________ ZIP _________________________ !In case of emergency, and we cannot contact you, who should we contact: Name ________________________________________________ Phone # _______________________ Address ______________________________________________ Alt. Phone # ____________________ City ____________________________ State _____________________ ZIP __________________ Relationship to applicant: _______________________________________________________________________________ !!Health History (Give approximate dates) Disease Allergies (Date not needed) ______Frequent Ear Infections ______ Chicken Pox _______Hay Fever ______ Heart Defect/Disease ______ Measles _______ Food ______ Diabetes ______ German Measles _______ Insect Stings ______ Bleeding/Clotting Disorder ______ Mumps _______ Penicillin ______ Hypertension _______Other Drugs (Please list below) ______ Mononucleosis _______ Asthma ______ Convulsions _______ Other (specify) __________________________ !!Please complete the following questions:

· Are you currently taking any prescribed medications? Yes _____ No _____ If yes, please specify medication and dosage: ____________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ · Are you currently using any non-prescription drugs on a regular basis, such as antihistamines or

sleeping aids? Yes _____ No _____ If yes, please specify: _________________________________________________________________________________ · Are you currently under a physician’s care for any illness? Yes _____ No _____ If yes, please explain: _________________________________________________________________________________ · Are there any medical conditions or physical limitations we should know about for this trip? · Yes _____ No ______ If yes, please explain: _________________________________________________________________________________ _________________________________________________________________________________ !• Do you have any allergies? Yes _____ No ______ If yes, please specify: _________________________________________________________________________________ _________________________________________________________________________________ !!!!!

Conduct Agreement !The rules and regulations of Bethany Baptist Church Student Ministries are designed to enhance the experience, protect each participant, and maintain a high level of integrity. The enforcement of all procedures and regulations are the responsibility of the Bethany Baptist Church staff, which includes adult volunteers serving as trip leaders. We reserve the right to send any student home due to improper conduct. The use or possession of alcohol or illegal drugs will result in immediate dismissal. A student and/or his/her family are responsible for any costs involved in sending the student home. !!!!!6. X________________________________________________________ Date:______________ Student Signature !!!7. X________________________________________________________ Date:______________ Parent Or Guardian’s Signature !!!!!!Student Contact Information and Camp Registration: !Name: Phone:_________________________ !!Email: Shirt Size:___________________ !!School Grade: DOB: !!1 Person you would like to room with: __________________________________________________ !

C,IMP BERACHAH MINISTRIESINpOnvpo CONsn,NI/RpTEASE op LTaSILITY

Dear Participant,

You are going to join us on a program involving the use of the Adventure Course. We are requesting thatall participants sign an Informed ConsenVRelease of Liability form.

The following describes the responsibilities of Camp Berachah, as well as the responsibilities of anyconsenting participant :

1. There will be strenuous physical activity involved. Although all individuals in average health will beable to comfortably participate, it shall be each individual's responsibility to be sure she/he ishealthy.l

2. Some activities will involve more risk2 than one engages in during normal daily routines. Eachindividual will be informed of the risk involved, and of the behaviors and skills necessary to safelycomplete the activity. The participant will choose whether or not to engage in the activity, andassume the risk on any potential physical or emotional injury or disability. Personal responsibility iskey to safety.

3. Camp Berachah requires that every participant have accident/health insurance coverage. In addition,certain medicallhealth infomation must be known by the instructor(s) facilitating the program, sothey are prepared to respond appropriately ifthe need arises.

4. No alcoholic beverage, tobacco, or use of any drugs is permitted on the course. Prescriptionmedication and any existing injury must be reported before the program.

the undersigned, agree to participate in the Camp Berachahprogram using the Adventure Course. I have completed the medicallhealthreview on the back of thissheet. I acknowledge that I have been advised that I can decline to participate in all or part of theactivities occurring during this program. I hereby release Camp Berachah and its contractors from anyand all liability with relationship to participation on _(aate). This release includes thetransportation to and from the site of the activities, as well as the activities themselves.

Signature Date

Parent signature (if child is under 18)

I The An-rerican liearl Associalion has published guidelines. u,hich are helplul" if 1ou have concems about cardiolascular stressduring the ropes challcngc course parlicipation (Circulation. r,ol. 82, no. 6. Dcc 1990. pp. 2286-2322). Infbrmation from thisrcport is summarized: "Exercise has both risks and bcncfits. N4ant,factors afl'ect risk of erercise. 'l'hree of the most imporlant areage. presence ofheart disease. and intensitl'olcxercise. Studies indicate that in the general population. risk ofsudden caldiacdcath during vigorous erercise is ver1,lou,. It is believed that the benefits ofexercise exceed the risks. and that individLralsshould bc cncouragcd to exercise. provided thel'take measures to minintize risk.''.

r Tn'o national sal'ct,r'studics have demonstrated ropes challenge cours!:s 1o bc l5 lime safer than clril'ing an autornobile.

Name

Home address

Daytime phone Evening phone

Name of physician

Address

Phone

Name of insurance

Emergency contact

Address

Group and ID number

Phone

Height Weight Sex_AgeHealth: Excellent Good Fair Poor

Please answer all of the questions.

1. Are you aware of any medicallhealth conditions that could be aggravated by physical activity, suchas: Heart disease, high blood pressure, lung disease, diabetes, asthma, seizures, pregnancy, or others?

Notr YesE describe

2. Are you aware of any problems with your neck, back, shoulders, wrists, hips, ankles, knees, or otherthat could be aggravated by physical activity?

Notr YesE describe

3. Have you had any major injury, illness, or surgery lately?

NoD YesE describe

4. Do you have any allergies?

Notr YesE describe

5. Do you take any medications?

NoE YesE describe

6. Do you have any minor or major disability? Do you use an orthopedic device?

Notr YesE describe