Liability Disclosure

Concordia Arrowhead Lutheran Camp’s programs involve a variety of activities which may include: warm up games, Group Initiative Course activities, high and low ropes course activities, rock climbing, and other rigorous physical adventure activities (The level of participation in any Concordia Arrowhead Lutheran Camp activity is at all times left to the individual’s personal discretion and choice). Yet, there is an inherent risk, which must be assumed by each participant, that he or she may possibly suffer a physical injury.

Policy for participation in all Concordia Arrowhead Lutheran Camp programs requires that each participant have health accident insurance coverage. In addition, certain health/medical information must be made known to the instructor(s)conducting the programs. This information is necessary so that the instructor(s) may be prepared to respond appropriately if the need should arise. This information will at all times be held in confidence. Please complete the following form and bring it with you to give to the instructor(s).

Name of Camp: ______Date of Event: ______

Application Information: (please print)

1. Name: ______Date of Birth: ____/____/______

2. Do you have Health/Accident Insurance? ______yes ______no

Please provide the name, address, and policy number of the

company below. ______

______

3. Do you have any physical disabilities or handicaps?

______yes ______no

If yes, please explain: ______

______

4. Are you currently taking any medication(s) prescribed or otherwise,

i.e. cold medications? ______yes ______no

If yes, please explain: ______

______

5. Do you have any allergies, restrictions to medications, or any other

physical limitations? ______yes ______no

If yes, please explain: ______

______

Release of Liability

I understand that parts of Concordia Arrowhead Lutheran Camp’s programs may be physically demanding. I am in good health and am not under a physician’s care for any conditions, disclosed or otherwise, that may hinder my ability to participate in physical activity.

I recognize and assume the inherent risk of physical injury that could occur during such programs.

I hereby release Concordia Arrowhead Lutheran Camp and its staff members and Board of Directors from all liability for any injury to me from participation in any of Concordia Arrowhead Lutheran Camp’s programs.

Date: ______

Participant’s Signature: ______

Parent or Guardian’s Signature (if under 18 years old): ______

In case of emergency, contact:

Name: ______

Phone: ______

Name: ______

Phone: ______

Photo/Media Release

I grant Concordia Arrowhead Lutheran Camp and acting media staff the right to use, reproduce, assign, and distribute photographs, films, videotapes, and sound recordings of myself for use in materials they may create for the purpose of promoting Concordia Arrowhead Lutheran Camp and its programs.

Date: ______

Participant’s Signature: ______

Parent or Guardian’s Signature

(If under 18 years old): ______

Medical Release

The above-signed participant has my permissions to take non-prescription medication (i.e. Tylenol, aspirin, ibuprofen, etc.) as deemed necessary by the Concordia Arrowhead Lutheran Camp Staff medical personnel.

Parent signature: ______

Date: ______

PLEASE COMPLETE REVERSE SIDE, TOO!!

PO Box 2387Lake Arrowhead, CA92352

Phone: (909) 336-1575 - Fax: (909) 337-9883