Fall Retreat Waiver

Please read this form carefully and be aware in registering your child you will be waiving and releasing all claims for injuries your minor might sustain arising out of this retreat. As the parent/guardian of a child participating in this retreat, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including death, damages, or loss which my minor child may sustain as a result of participating in any or all activities connected with or associated with such a program.

Emergency Contact Information

Parent/Gaurdian Name

Phone

Work Phone

Relationshiprelationship to child

Person to be called if neither parent can be reached:

Contact Name

Phone

Work Phone

Relationship

Medical Information

Health History(Asthma, diabetes, ADHD, ADD, etc.) Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?

0 /

AllergiesAre there any allergies we need to be aware of, including food, insect (ant, bee, etc.) or any other allergies?

0 /

Dietary Restrictionsother than food allergies

0 /

Activity Restrictions or Special Needs

0 /

Prescription and Non-Prescription MedicationsAre there any medications of which we need to be aware?

0 /

RELEASE AND WAIVER AGREEMENT 2019 (High School Fall Retreat)

I acknowledge and accept that there are elements of risk in any sport or activity associated with day retreat activities, including but not limited to sports, games, and other camp activities and the use of any equipment.

I, for myself and any minor children for whom I am a parent, legal guardian, or otherwise responsible, hereby release, acquit and forgive Hope Point Church, its directors, officers, agents, employees and volunteers for any and all liability of any nature for any and all injury or damage (including property damage, personal injury, illness, blindness, paralysis and/or death) to me or said minor children as the result of participation in the High School Fall Retreat.

I also give my permission for my child to participate in all activities during the retreat.

I authorize my child to be transported from Hope Point Church to the YMCA Blue Ridge Assembly in Black Mt. NC on a mini bus or carpool in another vehicle with other students that is operated by an adult driver.

I understand that Hope Point volunteers may take photographs and videos that include my child.

In the event that I cannot be reached in an emergency, I hereby give permission to Hope Point church to arrange necessary related transportation for my child and to secure and administer treatment, including hospitalization, for my child.

I verify that the information above is accurate. The completed form may be manually or digitally copied for Hope Point volunteers and Hope Point staff to use as necessary. I understand that in order for enrollment to be complete, I must complete and submit this Waiver Agreement.