MINOR ACTIVITY CONSENT AND MEDICAL RELEASE



MINOR ACTIVITY CONSENT AND MEDICAL RELEASE

Shepherd of the Hills/Hillcrest Christian Church

19700 Rinaldi Street, Porter Ranch, California 91326

(818) 831-9333

|Activity(s)/Date(s): |High School Summer Camp – August 8-13, 2010 |

| |COST: $299 early bird rate; $325 regular. A $50 non-refundable deposit is due by June 13 for early bird rate. |

| | |

| |REQUIREMENTS TO QUALIFY FOR EARLY BIRD RATE!!! |

| |Consent form (filled out in it’s entirety with ALL signatures, contact and medical info complete) PLUS non-refundable deposit of $50|

| |MUST be turned in by June 13 to qualify for early bird rate. |

| | |

| |NOTE: There will be a $ 20.00 fee for any checks returned NSF (Not Sufficient Funds). |

| | |

| |The High School Ministry of Shepherd of the Hills will be going to United Christian Youth Camp in Prescott, Arizona. Summer Camp |

| |will include normal and customary youth camp activities and events. Activities at the camp include, but are not limited to, |

| |climbing wall, zip line and trapeze jump activities, swimming, basketball, paintball, dodgeball, a talent show, team competitions. |

| |Activities will include skateboarding at a public skateboarding facility for some participants. These activities can be very |

| |hazardous. Helmets are required by the city. Each participant must provide his or her own helmet Supervision for all events and|

| |activities will be provided by the High School Ministry Staff and volunteers. Transportation for the entire week will be provided |

| |by a commercial transportation company. |

Sponsor: Shepherd of the Hills/Hillcrest Christian Church, a California religious nonprofit corporation, and its officers, directors, elders, employees, agents, volunteer workers, promoters and affiliates.

Location: This Minor Activity Consent and Medical Release covers all Activities on any Church campus or on any other property, including public property, used for or in connection with a Church sponsored event.

Name of Minor: Age:

Address:

Parents or Legal Guardian:

Name:

Address:

Daytime Phones: ( ) ( )

Email Address:

Name:

Address:

Daytime Phones: ( ) ( )

Email Address:

Nature of Activity(s): One or more activity listed above may involve outdoor sports and adventure activities. These activities are intended to provide various experiences and outdoor adventures to participants. The activities may take place at a venue owned and operated by an operator other than the Sponsor. Although not an exhaustive list, by way of example, these activities may include horseback riding, mountain biking, hiking, skateboarding, in-line skating, go-karts, obstacle courses, rock climbing, paint ball, laser tag, backpacking, camping, boating and water sports, including water skiing and swimming. Winter activities include skiing and snowboarding. Some may involve participation in public amusement rides such as roller coasters and other high risk rides. While it is impossible to foresee and describe all these future activities, these types of activities in particular involve a high degree of risk. Sponsor has no control over other participants in these activities, the weather or other elements involved. Many of these activities are supervised by the outdoor or adventure activity operator or owner and not by the Sponsor. One or more activity listed above may involve individual or team sports such as flag football, basketball, volleyball, softball, etc. All of these activities very in the degree of difficulty, skill and fitness required as well as the physical risk attendant to participation. Injuries are inevitable. Common injuries include cuts, scrapes, bruises, sprains, altitude sickness, poison oak, insect bites, etc. More serious injuries and or death can result, including, but not limited to, broken bones, head injuries, heat exhaustion, dehydration, and severe exposure to elements and in the case of waters sports, drowning. ALL THESE ACTIVITIES ARE BY THEIR NATURE, INHERENTLY DANGEROUS AND MAY RESULT IN INJURIES INCLUDING SERIOUS BODILY INJURY AND OR DEATH WHICH NO AMOUNT OF CARE, CAUTION, INSTRUCTION, SUPERVISION OR EXPERTISE CAN ELIMINATE. The activity may include contracted or private transportation and supervision by volunteers and counselors.

Acknowledgment: I represent that I am a parent or guardian having legal custody or the legal guardian of the above minor child. I, on behalf of my child, myself, our heirs, assigns and personal representatives acknowledge that the above activities, including the activities specifically listed, are inherently dangerous and may result in injuries, including serious bodily injury and/or death, which no amount of care, caution, instruction, supervision or expertise can eliminate. I further acknowledge that I have been fully and completely advised of the potential risks and dangers incident to my child(s participation in the activity and acknowledge that my child(s participation is voluntary and not as a requirement of Sponsor.

I further acknowledge that I have been informed and understand the degree of difficulty, ability and fitness necessary for my child to participate in the activity and represent and warrant that my child is sufficiently qualified to do so. I represent and warrant that I/we maintain personal health and/or accident insurance sufficient to cover bodily injury and/or damage resulting from my child(s participation in the activity. I represent that my child is currently in good health and has no known physical or mental conditions which would impair my child(s ability to participate fully in the activity.

Permission and Release: I give my permission for my child to participate in the activity described above. In consideration for my child's participation in this activity, I hereby, on behalf of my child, myself, our heirs, assigns and personal representatives, waive, release and forever discharge the Sponsor from any and all claims, including but not limited to claims for bodily injury, property damage, or death arising directly or indirectly from my child's participation in the activity, including injuries or losses caused by the ordinary negligence of Sponsor and the ordinary negligence, gross negligence and willful misconduct of third parties including other participants in the activity or as a result of any equipment failure or product defect arising in connection with the activity.

I, on behalf of my child, myself, our heirs, assigns, and personal representatives, state that I am aware of the risks associated with the activity and freely assume full responsibility for the risk of bodily injury, property damage, or death to my child while engaged in the activity due to the ordinary negligence of Sponsor and the ordinary negligence, gross negligence, or willful misconduct of any third party including others participating in the activity or as a result of any equipment failure or product defect arising in connection with the activity.

I, on behalf of my child, myself, our heirs, assigns, and personal representatives, agree to indemnify, defend and hold harmless, at my sole cost, the Sponsor from any and all claims arising out of my child's participation in the activity.

Any provision or portion of this Minor Activity Consent and Medical Release found to be invalid by a court having jurisdiction shall be invalid only with respect to such provision or portion thereof, and then only to the extent necessary to avoid such invalidity. The offending provision or portion shall be modified to the maximum extent possible to confer upon the parties the benefits intended thereby. The provision or portion as modified and the remaining provisions or portions hereof shall be construed and enforced to the same extent as if such offending provision or portion thereof had not been contained herein, to the maximum extent possible.

Additional Releases: I further understand that the owner or operator of the outdoor or adventure activity may require separate and additional releases in order to participate in the activity. I understand that Sponsor has no control over the contents or requirements of such additional releases and that the terms and conditions of this Minor Activity Consent and Medical Release are not affected by the presentation, acceptance, or signing such additional releases.

Foreign Country Supplement: If the activity includes travel to a foreign country a Foreign Country Supplement to this Minor Activity Consent and Medical Release is required to be attached.

Medical Release: I affirmatively state that my child is in good health and has no known physical or mental conditions which would impair or restrict his/her participation in the activity. Pertinent general medical information and conditions concerning my child are as follows:

(Please list disabilities, allergies, health or activity limitations, etc.)

In the event my child suffers sudden illness, accident, or injury, I give permission and authorize Sponsor to provide emergency aid and to provide or authorize such emergency transport and medical treatment that is deemed necessary by any paramedic, emergency medical technician, physician, or dentist (health professional). In the event hospital treatment is deemed advisable by the health professional, and Sponsor is unable to reach the parents or legal guardian or the emergency contact listed below, I authorize the hospital or urgent care facility most assessable at the time of accident or during the illness to administer any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital or temporary emergency care which is deemed advisable and may be rendered under the general and special supervision of any physician and surgeon on the medical staff of said hospital or emergency care facility, whether such diagnosis or treatment is rendered at the hospital or emergency medical facility or at the office of the physician.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of Sponsor, its agents and employees, to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned health professional in the exercise of his/her best judgment may deem advisable.

Family Physician - Health Care Organization

Phone ( )

Emergency Contacts other than parent or guardian listed above:

1. Name: Home Phone: ( )

Work Phone: ( )

2. Name: Home Phone: ( )

Work Phone: ( )

Medical Insurance Company/HMO: (if other than above):

Policy No: Phone: ( )

Mediation/Arbitration: I further agree that any claim or dispute arising from or related to this Minor Activity Consent And Medical Release, and the subject matter thereof shall be settled by mediation and, if necessary, legally binding arbitration, in accordance with the Rules of the Institute for Christian Conciliation; judgment upon an arbitration award may be entered in any court otherwise having jurisdiction. If a dispute or claim involves a claim as to which the Sponsors' insurance, or the Sponsors' insurance with respect to Sponsors' officers, directors, elders, employees, agents, volunteer workers, promoters or affiliates, if any, applies, and if the Sponsors' insurer elects not to submit the dispute or claim to mediation or arbitration, as described in this Mediation/Arbitration provision, unless the parties otherwise agree, this Mediation/Arbitration provision shall no longer be applicable with regard to the part of the dispute or claim as to which the Sponsors' insurance applies. I agree that this Mediation/Arbitration provision shall be the sole remedy for any dispute arising between me, my child, and the Sponsor, and do hereby waive, on behalf of myself, and my child, the right to file any legal action against the Sponsor in or before a civil court or agency, except to enforce an arbitration decision.

I/we consent, give permission and agree:

Print Name: Relationship to Minor

Signature Date:

Print Name: Relationship to Minor

Signature Date:

Approved:

SHEPHERD OF THE HILLS/HILLCREST CHRISTIAN CHURCH

BY: DATE:

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