PARTICIPANT INFORMATION
First Name: Last Name: Middle Initial:
Birthdate: Gender:
Home Address: Home Phone:
EMERGENCY CONTACTS
Spouse/First Emergency Contact Name:
Home Address:
Home Phone: Business Phone: Cell Phone:
Second Emergency Contact Name:
Home Address:
Home Phone: Business Phone: Cell Phone:
MEDICAL INFORMATION
Any allergies or other medical needs?
Physician Name:
Address:
Medical Insurance Company: Policy Number:
Address:
Phone: Website:
RELEASE OF LIABILITY AND ASSUMPTIONS OF RISK
INDEMNITY AND CONTRACT AGREEMENT: I will not hold or attempt to hold Young Life liable for any loss, damage or injury to person or property caused by any act or neglect of other persons on or about the Property, or caused in any manner other than the willful or grossly negligent act of Young Life, its agents and employees, and will indemnify and hold Young Life harmless from any liability for damages or claims against Young Life arising out of or in any way related to any such loss, damage or injury. I release Young Life, including its trustees, employees and agents, from my physical injury, including death, or illness while at the Property. I will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.
AUTHORIZATION FOR TREATMENT: I hereby give permission to the medical personnel selected by the camp director to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person.
To obtain a copy of Young Life’s Notice of Privacy Practices, log on to www.younglife.org or call (719) 867-3600.
I verify that I am or my child is in good health and am capable of participating in strenuous activities, and when necessary, will tailor my activities to those within the bounds of my physical health.
In Colorado, campers will participate in rigorous activities at 9,000 to 14,000 feet. I recognize that any medical treatment and/or medical transportation that is provided to me or my child while attending a Young Life camp will be paid for by my medical insurance company.
Canada: Malibu Club/Beyond Malibu: I agree that any complaint, demand, dispute, claim involving bodily injury including death and/or personal injury or cause of action arising out of or in any way related to Young Lie’s Malibu Club or Beyond Malibu, including any activity, event, medical treatment, and/or transportation will be governed by the laws and jurisdiction of the Canadian Province where the event or incident occurred.
COVID-19: I recognize that a national emergency was declared because of the COVID-19 outbreak and that different states and/or counties/cities may be in various states of emergency. I recognize that even if Young Life has taken reasonable actions in light of COVID-19 and other coronaviruses, there is no guarantee that me or my child will not contract/transmit COVID-19 or other infectious or contagious illnesses or diseases while participating in activities and events at the Young Life property/camp, or traveling to and from, Young Life’s camp property and I release Young Life in the event of such an occurrence. The Center for Disease Control (CDC) has identified that certain individuals are at Higher Risk for Severe Illness if they become ill with COVID-19. This includes those who have chronic lung disease, moderate/severe asthma, a serious heart condition, are immunocompromised, or have severe obesity, diabetes, or chronic kidney/liver disease or who are over the age of 65. Based on the CDC’s High-Risk criteria, you have determined if you want to participate in this event or if you want your child to participate in this event.
WAIVER AND RELEASE If I am under the age of 18, or under the age of 19 if attending Malibu Club or Beyond Malibu, my parent or guardian, by signing below, also consent to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns. My parent or guardian also promises, by signing below to defend, indemnify and hold Young Life harmless from any claim asserted by me against Young Life, including its trustees, employees and agents, if I should repudiate this release after obtaining adulthood.
Name of Group/Church: Cornerstone Chapel
Event Date: January 12-15, 2024
