Cornerstone Chapel

NorthBay - YA001


Note to Guest: NorthBay wants the camp 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.

Group Name: Cornerstone Chapel

Last Name:   First Name:   Middle Name:  
Birthdate: Gender:
Cell Phone:  
E-mail Address:  
Home Address:   Home Phone:  
Emergency Contact:   Relationship:   Cell Phone:  
Home Address:   Home Phone:  
My Insurance Company:   Policy Number:  
NorthBay reserves the right to subrogation if it is later determined that personal medical insurance was in place.
List any major medical conditions:  
List any allergies to medications:  

At NorthBay, health, safety, and supervision are paramount. The approach to safety and risk management is accompanied with competence, judgment, and purposeful sound programming. Guest safety and well-being is everyone’s concern. As a policy of NorthBay, we require that a Release of Liability Form be signed as a requirement to attend camp.

I represent that I desire to attend a camp and participate in activities sponsored by NorthBay Education Inc.(“NorthBay”). In consideration for NorthBay permitting the Guest to attend the camp and participate in the activities, I have agreed to execute this Release of Liability and Assumption of Risks (the “Release”). I assert the information given on this health form is complete and accurate to the best of my knowledge.

I acknowledge that participating in some of the activities sponsored by NorthBay, including canoeing, kayaking, boating, water skiing, hiking, swimming, snorkeling, tubing, fishing, rock climbing, zip line, sport activities, nature and acclimatization activities, and using the ropes course, involve certain inherent risks, including the risk of serious personal injury. I agree I shall assume all such risks, including the risk of serious personal injury. I agree I shall assume all such risks, as well as any other risks involved in any activities sponsored by or involving NorthBay.

I also agree to release and discharge NorthBay and all of its employees, agents, and representatives, as well as all other persons, corporations, or other entities that might have any liability to or me (the "Released Parties"), from and against any and all damages, actions, claims, and liabilities, whether known or unknown, anticipated or unanticipated, suspected or unsuspected, relating to or arising from me attending camp or being involved in any activity, occurrence, or event connected to Northbay.

This Release is intended to release and discharge the Released Parties from all damages, actions, claims, and liabilities arising from or related to the negligence of the Released Parties. I further agree to indemnify, hold harmless, and defend NorthBay from and against any loss, damage, liability and expense, including costs and attorneys’ fees, incurred by NorthBay that is related to or arise from me attending camp or being involved in any activity, occurrence, or event connected in any way to NorthBay. I hereby grant permission to NorthBay the right to use, reproduce, and/or distribute photographs, films, video-tapes, and sound recordings of me, without compensation or approval rights, for use in materials created for purposes of promoting the activities of NorthBay.

The laws of the State of Maryland shall govern the rights and obligations of the parties to this Release and the interpretation, construction, and enforceability thereof. I agree that any lawsuit brought against any Released Party shall be brought solely in the Circuit Court for Cecil County, Maryland. I hereby voluntarily waive any right I may have to a trial by jury in any action, proceeding or litigation involving any Released Party. I further agree to pay any attorney’s fees incurred by NorthBay if I attempt to contest the validity of this Release.

In the event I cannot be reached in an emergency when I am under camp supervision, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and/or order injections, anesthesia, or surgery for myself. If something were to happen to me a doctor selected by the camp may treat me for any injury/illness.


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Signature Certificate
Document name: NorthBay - YA001
lock iconUnique Document ID: b768b7a161867fcc1996eac77244e6bea4ce7ddd
Timestamp Audit
February 2, 2022 4:15 pm EDTNorthBay - YA001 Uploaded by Cornerstone Chapel - IP
February 2, 2022 4:22 pm EDTYoung Adults - added by Cornerstone Chapel - as a CC'd Recipient Ip: