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Woodmen Valley Chapel & First Pres Colorado Springs

Activity Release and Consent High School Winter Camp (Adult) PLEASE READ CAREFULLY BEFORE SIGNING. THIS DOCUMENT INCLUDES A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS. Acknowledgment of Risks. I hereby agree to participate in High School Winter Camp sponsored by Woodmen Valley Chapel and First Pres Colorado Springs. I understand that there are risks associated with participation in High School Winter Camp activities, which may include walking, running, hiking, climbing, riding, swimming, and transportation to and from camp activities. Many risks are inherent in such activities, and because they take place in a camp environment, these risks cannot be eliminated, altered, or controlled. For example: • Weather conditions may change rapidly and unpredictably and may cause injury directly (for example, rain or hail storms, sunburn, lighting strikes, cold temperatures, and the like) or by acting upon other factors (for example, performance of equipment may be impaired by weather conditions). • Equipment used in the activity may break, fail, or malfunction despite reasonable maintenance and use. Some of the equipment used in activities may inflict injuries even when used as intended. Persons using equipment may lose control of such equipment and cause injury to themselves and to others. • Most activities take place in a natural environment where unexpected, unseen, and unmarked objects and conditions create risk of injury or death from falling, tripping, slipping, insect or animal contact, unstable surface conditions, falling rocks and objects, potentially harmful vegetation, and the like. • Activities near or in the water involve risk of injury, illness, slipping, falling or drowning. Because they are in a natural environment, lakes, ponds, streams, rivers, creeks and swimming pools present risks of water movement, subsurface conditions, cold water temperatures, water impurities, and the like. There is also a risk of falling out of or being struck by watercraft. • Counselors and guides use their best judgment in determining how to react to circumstances, including weather, terrain, water conditions, animal character, and other unpredictable natural phenomena. The counselors and guides may misjudge such circumstances, an individual’s capabilities, and the like. • Motor vehicle accidents may occur in the course of transporting camp participants to or from activities. • High School Winter Camp participants may be exposed to unfamiliar climates, altitudes, and physical environments, and such exposure may cause adverse health effects. These are some, but not all, of the risks inherent in High School Winter Camp activities. A complete listing of inherent and other risks is not possible. There are also many risks, which cannot be anticipated. I agree to participate in High School Winter Camp activities, including those described above. I acknowledge and fully assume the risks associated with these activities. I UNDERSTAND THAT ALL HIGH SCHOOL WINTER CAMP ACTIVITIES, INCLUDING THOSE DESCRIBED ABOVE, INVOLVE THE RISK OF DAMAGE, LOSS, ILLNESS, INJURY, AND DEATH. Waiver, Release, and Indemnification. I hereby release and waive any claim of liability against Woodmen Valley Chapel, First Pres Colorado Springs and its officers, directors, ministers, employees, agents, and volunteers (together, “Released Parties”) with respect to any damage, loss, illness, injury, or death related to or arising out of my participation in High School Winter Camp. I also agree to indemnify and hold harmless the Released Parties with respect to any claim asserted by or on my behalf as a result of damage, loss, illness, injury, or death related to or arising out of my participation in High School Winter Camp.

I UNDERSTAND THAT THIS WAIVER AND RELEASE APPLIES TO ALL CLAIMS, INCLUDING CLAIMS ARISING OUT OF THE NEGLIGENCE OF THE RELEASED PARTIES, but does not apply to claims of criminal conduct, intentional or reckless tortious acts, or gross negligence. Medical Consent, Release, and Indemnification. In case of medical need or injury, I understand that Woodmen Valley Chapel and First Pres Colorado Springs will make reasonable efforts to contact my emergency contact. In the event that my emergency contact cannot be reached, I authorize Woodmen Valley Chapel to arrange for medical services for me and to release any medical information or records necessary therefor. Any provider of care can rely on this document as authority to treat me as appropriate and to bill me directly for the costs thereof. I understand that I am responsible for any medical and related expenses for myself. I hereby waive and release any claim of liability against the Released Parties arising out of the authorizing of medical treatment under the terms of this consent. I further agree to indemnify and hold harmless the Released Parties for any damages, liability, or costs related to or arising out of the same. I understand that I am responsible for communicating any food allergies or other relevant medical conditions to Church staff on the Church form entitled Relevant Medical Information.

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Governing Law and Venue. I agree that this Activity Release and Consent shall be governed exclusively by the laws of the state of Colorado. I further agree that any claims arising out of or related to this Activity Release and Consent, including any and all claims arising out of or related to my participation in High School Winter Camp, shall be filed exclusively in El Paso County, Colorado. Authority to Enter Agreement. By signing this agreement, I warrant that I have the legal power, right, and authority to make this agreement and to bind myself hereto.

Date

Signature Printed Name

Address Home Telephone

Work Telephone

Cell Telephone

Emergency Contact

Relationship

Telephone

Relevant Medical Information Name of Participant: Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: NAME OF MEDICATION

PURPOSE/CONDITION BEING TREATED

May the Church give you Tylenol or aspirin for headaches or pain?

Yes

Does you have any allergies or special medical conditions of which we should be aware?

Date

Signature Printed Name

Page 2 of 2

TIME(S) OF ADMINISTRATION & DOSAGE

No