REGISTRATION/MEDICAL RELEASE FORM

(Must be filled out by all campers)

Camper’s Name______Age______Sex______Birthdate ______

Address______City______State/Zip ______

Phone # ______Church______

Pastor ______City ______State/Zip ______

Are you taking any MEDICINE? Yes ____ No ____ If yes, please specify______

Are you taking any PRESCRIPTION MEDICATION? Yes ______No ______

If yes, please specify ______

(Please report to the camp nurse for supervision)

What “over the counter” medications are you allowed to take? ______

Do you have any medical condition(s), which may limit your foods or activities? Yes ______No ______

If yes, please specify______

(Please report to the camp nurse for supervision)

Please list any current or chronic health problems______

Do you have any allergies? Yes ____ No ____ If yes, please specify______

Family Doctor ______Doctor’s Phone # ______

Name of Primary Medical Insurance______

(Please bring a copy of your INSURANCE CARD or DSHS COUPON.

If DSHS has HEALTHY OPTIONS bring a copy of the card that goes with the coupon)

In case of an accident, does the parent or legal guardian give permission for medical treatment if necessary?

Yes ____ No ____ If no, please explain______

I accept all responsibility for refusing medical assistance:

X______

Signature of Parent or Legal Guardian

(Any complications or added problems due to not giving permission is parent or guardian’s responsibility)

In case of an accident, does the parent or legal guardian give permission to transport if an injury occurs?

Yes ____ No ____ If no, please explain what you would like us to do______

In case of emergency, please contact:

______

Name Relationship Phone #

X______

Signature of Parent or Legal Guardian Date

RELEASE AND ARBITRATION AGREEMENT

(Must be signed by all attendees)

In consideration of the Washington Independent Baptist Fellowship (WIBF), Camp Graceway, Bible Baptist Church and Reggie and Carolyn Bartkowski, I for myself, or the minor child named below, forever waive, release and discharge the WIBF, Camp Graceway, Bible Baptist Church

and Reggie and Carolyn Bartkowski from any/all injuries, claims, disputes, liabilities, or actions resulting from the WIBF, Camp Graceway, Bible Baptist Church and Reggie and Carolyn Bartkowski providing services for me and for my benefit regardless of locations for the dates identified above. I attest and verify that I have full knowledge of the risks and dangers involved; that I assume such risks, and that I will assume and pay my own medical and emergency expenses, in the event of an accident, illness or other incapacity, regardless of whether I

have authorized such expenses.

Any controversy arising out of, connected to, or in relation to any matter herein of the transactions between me and the above named parties,

or on behalf of the minor child named below, of the Release/Waive, or the breach thereof, including, but not limited to any claims of violations

of Federal and/or State Law, as well as any common law claims shall be settled by arbitrations through Christian Conciliation Services; and in

accordance with this paragraph a judgment based upon the arbitrator’s award may be entered in any court having jurisdiction thereof in

accordance with the provision of RCW 7.04. This agreement shall be construed and interpreted under laws of the State of Washington. I HAVE

READ THIS WAIVER AND RELEASE CAREFULLY, AND UNDERSTAND IT.

______

Campers Name

______

Signature & Date of Parent or Legal Guardian

______

Church/City/State

------

RELEASE AND ARBITRATION AGREEMENT

(Must be signed by all attendees)

In consideration of the Washington Independent Baptist Fellowship (WIBF), Camp Graceway, Bible Baptist Church and Reggie and Carolyn

Bartkowski, I for myself, or the minor child named below, forever waive, release and discharge the WIBF, Camp Graceway,

Bible Baptist

Church

and Reggie and Carolyn Bartkowski from any/all injuries, claims, disputes, liabilities, or actions resulting from the WIBF, Camp

Graceway,

Bible Baptist Church

and Reggie and Carolyn Bartkowski providing services for me and for my benefit regardless of locations for the dates identified above. I attest and verify that I have full knowledge of the risks and dangers involved; that I assume such risks, and that I will assume and pay my own medical and emergency expenses, in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses.

Any controversy arising out of, connected to, or in relation to any matter herein of the transactions between me and the above named parties, or on behalf of the minor child named below, of the Release/Waive, or the breach thereof, including, but not limited to any claims of violations

of Federal and/or State Law, as well as any common law claims shall be settled by arbitrations through Christian Conciliation Services; and in accordance with this paragraph a judgment based upon the arbitrator’s award may be entered in any court having jurisdiction thereof in

accordance with the provision of RCW 7.04. This agreement shall be construed and interpreted under laws of the State of Washington. I HAVE

READ THIS WAIVER AND RELEASE CAREFULLY, AND UNDERSTAND IT.

______

Campers Name

______

Signature & Date of Parent or Legal Guardian

______

Church/City/State