CHARTER OAK YOUTH STUDENT RELEASE FORM

EVENT: Charter Oak Winter Camp 2016, Friday Feb. 26th-28th.

CONTACT PERSON: Robby Plasencia 253-678-9876

DESCRIPTION OF EVENT: This is our annual get-away to the snow for a time of relaxation and fun with great friends. We will stay 2 nights at the Lodges at Salmon River Meadows. Cost: $135. All meals, gas, and lodging is included. Arrive at Charter Oak at 5pm Friday, Feb. 26th and return Sunday, Feb. 28th at 2pm. Our adult chaperones and drivers make your child’s safety a priority. Please pack snow clothes, sleeping bag/pillow, overnight essentials. If you have any questions please contact Robby Plasencia.

STUDENT INFO:

Participant (Student):______Age:______

Parent/Guardian:______Phone:______

Home Address:______

Emergency Contact Person:______Phone:______

Medical Insurance Company:______Policy #:______

PARENT/GUARDIAN AGREEMENT*:

We, the undersigned parents/guardians, of the above named participant, grant permission for the participant to participate in events sponsored by Charter Oak Community Church.

We, as parents/guardians, understand that this event/activity, as in any event/activity for youth; does present the risk of injury, or even death, to the participant, rare as that may be, and we have advised the participant of those possibilities. We represent to you that we and the participant assume the risk of any such injury or death, and hold you, your agents, employees and representatives harmless from any liability to any person or entity arising as a result of the conduct of the participant in this event/activity and agree to indemnify you, your agents, employees and representatives against any claim or liability arising as a result of such conduct.

If we, as parents/guardians, are not personally at these events/activities in which the child participate, so as to be consulted in the case of necessity, you are authorized, on our behalf to arrange for such medical and hospital treatment as you may deem advisable for the health and well-being of the participant.

My child has medical insurance and is under supervision of Charter Oak Community Church.

My child has no medical insurance. I agree to hold Charter Oak Community Church and its agents harmless of any medical expenses that may arise during my child’s participation during this event. I will be solely responsible for any and all medical expenses.

Events/activities include any of the following: Outdoor and indoor games, motorized carts, bicycling, carnival rides, hiking, food service, snow sledding, swimming, overnight housing, Frisbee, volleyball, basketball, youth seminars and rallies, music concerts, and similar related activities.

PARTICIPANT/ STUDENT AGREEMENT:

I, as the participant, understand that while in attendance of all Charter Oak Community Church events/activities, am under the direction and authority of those leaders in charge. I also understand that the use of alcoholic beverages, illegal drugs, tobacco, fireworks, foul language, abusive and lewd behavior are prohibited. I am expected, as a participant, to be with the group at all times. Any variance in the rules and/or events/activities may result in immediate expulsion by asking my parents/guardians to pick me up. I understand that this is a Christian event/activity and will have a spiritual emphasis.

PARENT/GUARDIAN SIGNATURE:______DATE:______

PARTICIPANT/STUDENT SIGNATURE:______DATE:______