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Harvest Youth 2019 Summer Camp - Riverside on Friday, August 30, 2019

1No Charge 
1No Charge 
*Attendee's Age:
*Attendee's Gender:
*Attendee's Grade:
Roommate Request #1:
Roommate Request #2:
Roommate Request #3:
PARENT INFO
*Parent Name:
*Parent Phone:
*Parent Email:
EMERGENCY INFO
*Emergency Name #1:
*Emergency Phone #1:
*Emergency Name #2:
*Emergency Phone #2:
MEDICAL INFO
*Does Attendee have any Allergies?
If yes, please explain:
Is Attendee currently taking Medication?
If yes, please explain:
To assure the safety and health of my child, I hereby authorize and appoint, as my attorney-in-fact, Harvest Christian Fellowship and representatives of the church, Camp Director, camp medical staff, R.N., or EMT to arrange for medical and dental care, and to give oral or written consent on my behalf for medical or dental treatment, including surgery deemed necessary by the licensed physician.
 I, the Participant (or parent/guardian if Participant is a minor), acknowledge that I have read, understand and agree to the following Consent to Treatment:
RELEASE FORM
I, the Participant (or parent/guardian if Participant is a minor), acknowledge that participation in and transportation to and from the Activity described involves risk to the Participant (and to Participant's parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. 

I, the Participant (or parent/guardian if Participant is a minor), accept personal financial responsibility for any injury or other loss sustained during the Activity or transportation to and from the Activity, as well as for any medical treatment rendered to the Participant that is authorized by Harvest Christian Fellowship, employees, volunteers, or any other representatives (collectively referred to hereinafter as "Harvest"). 

I, the Participant (or parent/guardian if Participant is a minor) acknowledge, understand and assume the risks inherent in recreation activities and that said activities entails risks of physical injury to his/her person and property and that the Participant is participating with full knowledge of said risks; conditions of the various recreation facilities, outdoor areas, basketball courts and adjacent school or park grounds and parking lots; any action or cause of action arising from (1) the performance, or failure to perform, maintenance, inspection, supervision, control or security of said areas, (2) the failure to warn of dangerous conditions as existing on or near said locations, or (3) any action by the spectators or (4) negligent supervision or selection of officials, spectators, players or coaches or (5) any hidden, latent or obvious defects or dangerous conditions existing on or near said locations. 

I, the Participant (or parent/guardian if Participant is a minor), EXEMPT, RELIEVE, RELEASE and PROMISE TO INDEMNIFY, DEFEND and HOLD HARMLESS, Harvest FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE AND WRONGFUL DEATH CAUSED BY THE PASSIVE OR ACTIVE NEGLIGENCE, for any injury arising directly or indirectly out of the described Activity or transportation to and from the Activity, whether such injury arises out of the Participant, or otherwise. If a dispute over this agreement or any claim for damages arises, I, the Participant (or parent/guardian if Participant is a minor), agree to resolve the matter through a mutually acceptable alternative dispute resolution process. If I, the Participant (or parent/guardian if Participant is a minor), and Harvest cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution, pursuant to the rules of the American Arbitration Association. 

I, the Participant (or parent/guardian if Participant is a minor), am only driving myself/family members to this Activity. (NOTE: if either I, the Participant, or parent/guardian drive anyone other than myself or family to this Activity, a Volunteer Driver Form MUST be on file with the ministry, including a copy of a valid driver’s license and insurance declaration page.)
*I, the Participant (or parent/guardian if Participant is a minor), acknowledge that I have read, understand and agree to the following Hold Harmless Waiver:
*I, the Participant (or parent/guardian if Participant is a minor), grant permission for Participant to be Photographed and/or Videotaped during this event: