Medical & Liability Release printable pdf download

MEDICAL &

FOR OFFICE USE ONLY

CABIN NUMBER

CHURCH/GROUP:__________________________________________

LIABILITY

q Female

q Male

H E A LT H I N F O R M A T I O N

Please 1 (one) camper (adult or child) per form & print clearly in blue or black ink.

RELEASE

Family Doctor: _____________________________________________________ Phone: (______)__________________

All individuals at camp must have a completed form on file.

Insurance Carrier: __________________________________________ Policy Number: _____________________________

Are there any medical conditions we should know about? q Yes q No

Nature and Extent: _________________________________

CAMPER NAME (adult or child): ________________________________________________________________________

____________________________________________________________________________________________

PARENT EMAIL ADDRESS: __________________________________________________________________________

List all medications brought to camp along with dosage and frequency: ________________________________________________

____________________________________________________________________________________________

In case of emergency, notify: ________________________________________ Relationship: __________________________

All medications must be turned in to the infirmary. Medications must be in original container, labeled,

with specific written dispensing instructions by a parent, legal guardian or medical doctor.

Home Phone: (______)__________________ Work: (______)__________________ Cell: (______)__________________

If needed, may a health tech dispense (check box if answer is yes):

q Tylenol?

q Advil?

q Pepto Bismol/Tums?

q Cough Syrup?

FOOD SERVICE REIMBURSEMENT PROGRAM:

The financial information you provide below allows us to participate in a food grant program. This program

Is the camper allergic to any medications or foods? q Yes q No

If yes, please explain: ____________________________________

allows us to keep our cost of camp among the lowest in all of Southern California while still maintaining amazing programming and facilities. Please help us to maximize this

______________________________________________________________ Date of Last Tetanus Shot: ______________

program by being as thorough as possible. The information is confidential and will not be shared for any other purpose.

Camper insurance begins where individuals health and accident insurance policy terminates. It is only valid when other insurance has been extended to its limits. In case of no

If camper is under age 18, please complete the next sections of this form. Your information is confidential. You may return this completed form directly to Ponderosa Pines

personal policy, Ponderosa Pines’ policy will provide coverage within its limits for accidents only ($1000 per injury).

Camp by fax (909-867-3991) or to your Camp Coordinator.

In case of emergency, I hereby give permission to the physician selected by the camp to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery

1. Does the child qualify for “Free” or “Reduced” Breakfast or Lunch at school?

for my child/the camper as named above. It is understood that the camp and doctor will make every effort to contact the parent/guardian of the child before treatment.

If so, please note the School Name and School District that they attend, here:

PHOTOGRAPHY: Registering for camp gives Ponderosa Pines permission to use your child’s likeness in print, video or on the internet for promotional purposes.

School: _____________________________________ District: ___________________________________________

OFF-SITE TRANSPORTATION: Registering for camp gives Ponderosa Pines permission to transport your child to off-site activities if applicable.

2. Is the child is a Foster child. q YES or q NO

If yes, skip to the “Health Information” section.

DISCIPLINE POLICY: I understand that my child comes under the authority and reasonable guidelines of Ponderosa Pines and may be sent home in the event of a violation

3. Do you or the child receive any type of Welfare or State Assistance? q YES or q NO

of the rules. If this should occur, I agree to come and get my child immediately.

• If so, please indicate the name of that assistance here: _________________________________________________________

PA RT I C I PAT I O N , R EL EA S E, WA I V E R & I N D EM N I T Y AG RE E M E N T

• List the associated Case Number here: ___________________________________ Then skip to the “Health Information” section.

WHILE PONDEROSA PINES CHRISTIAN CAMP MAKES EVERY EFFORT TO PROVIDE A SAFE AND PLEASANT ENVIRONMENT FOR YOUR CHILD, WE DO REQUIRE

4. How many people are you financially supporting? _____________________________

THAT THIS PARTICIPATION AGREEMENT BE READ, FILLED OUT, SIGNED AND DATED BY THE PARENT OR LEGAL GUARDIAN OF EACH CHILD UNDER 18 YEARS OF

List names of household members: _____________________________________________________________________

AGE WHO WISHES TO PARTICIPATE IN THE ACTVITIES WHICH OCCUR AT PONDEROSA PINES.

_____________________________________________________________________ __________________

I, the undersigned, give permission the aforementioned camper to participate in the activities that occur at Ponderosa Pines Christian Camp, and on our around Ponderosa

5. What are the last four digits of your social security number? ___ ___ ___ ___

q Check here, (“X” or “ ”), if no Social Security Number.

Pines. These activities include, but are not limited to, swimming in the pool, hiking, climbing, archery, disc golf, tetherball, horse shoes and strenuous competition games. I

grant this permission with full knowledge that I accept full responsibility for any injury or accident that may occur.

Complete this section only if YOU DO NOT receive assistance from the above programs

Although Ponderosa Pines Christian Camp has taken reasonable steps to provide equipment and skilled employees so your child can participate in activities for which he/she

Annual Household Income From All Sources: (PLEASE CHECK ONE)

may not be skilled in, we now remind you that these activities are not without risk. Certain risks cannot be eliminated due to the camp’s rural setting and without destroying

q $21, 978 and below

q Between $37,297–$44,955

q Between $60,274–$67,951

the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury,

illness or in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you

q Between $21, 979–$29,637

q Between $44,956–$52,614

q Between $67,952–$75,647

to be informed and know in advance about the inherent risks.

q Between $29,638–$37,296

q Between $52,615–$60,273

q $75,648 and above

I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Ponderosa Pines Christian Camp, Inc., its officers, Board, agents or employees, for

any and all claims for injuries, causes of action, or liability related to my child’ s participation in any activity occurring at Ponderosa Pines Christian Camp, or on or around Ponderosa

THIS SECTION IS OPTIONAL. THE REQUESTED INFORMATION IS FOR STATISTICAL PURPOSES ONLY.

Pines. This release does not apply to intentional and/or willful acts of misconduct by Ponderosa Pines Christian Camp or any of it’ s officers, Board, agents or employees.

1. CHECK ()

ALASKAN NATIVE OR

BLACK OR

NATIVE HAWAIIAN OR

Should Ponderosa Pines Christian Camp or anyone acting on their behalf, be required to incur attorneys’ fees and costs to enforce this agreement, I agree to indemnify and hold

ASIAN

WHITE

RACIAL IDENTITY:

AMERICAN INDIAN

AFRICAN AMERICAN

OTHER PACIFIC ISLANDER

Ponderosa Pines Christian Camp harmless for all such fees an costs.

2. IS PARTICIPANT OF HISPANIC OR LATINO ORIGIN

YES

By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child’s participation in these activities, I and/or my child my be found

by a court of law to have waived any right to maintain a lawsuit against Ponderosa Pines Christian Camp on the basis of any claim which has been released herein. I have had

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin,

sufficient opportunity to read this entire document. I have read and understood it and agree to be bound by it’s terms.

sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW,

Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA, CDE and Camp Pondo are an equal opportunity provider and employer.

Section 9 of the National School Lunch Act requires that, unless the participant’s food stamp, CalWORKs, Kin-GAP, or FDPIR number is provided, you must include the last four

digits of the Social Security # of the household member signing the statement or an indication that they do not possess a Social Security Number. Provision of a Social Security

FOR OFFICE USE ONLY

Number is not mandatory, but if a Social Security Number is not provided or an indication is not made that the adult household member signing the statement does not have

MONTHLY INCOME CONVERSION

HOUSEHOLD

TOTAL HOUSEHOLD

NOT ELIGIBLE

CATEGORICALLY ELIGIBLE

one, the statement cannot be approved. The Social Security Number may be used to identify the household member in carrying out efforts to verify the correctness of informa-

WEEKLY ................................................X52

SIZE

MONTHLY INCOME:

tion stated on the statement. Verification efforts may be carried out through program reviews, audits and investigations, and may include contacting employers to determine

FOSTER CHILD

INCOME ELIGIBLE

EVERY 2 WEEKS (BI-WEEKLY) ................X26

income, contacting a social service office to determine current certification of Food Stamp, CalWorks, Kin-GAP, FDPIR benefits, contacting the State Employment Development

TWICE A MONTH (SEMI-MONTHLY)........X24

Department to determine benefits received, and checking documentation provided by the household member to prove the amount of income received. These efforts may result

DESIGNATED OFFICIAL:____________________________________________________

DATE: _______________________________

in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. USDA is an equal opportunity provider and employer. I certify that

all of the above information is true and correct and I voluntarily sign it.

PONDEROSA PINES CHRISTIAN CAMP, INC.

In accordance wit h Federal law and US Department of Agriculture policy, the institution is prohibited from discriminating on the basis of race, color, national origin, sex, age,

P.O. B ox 1 247 •

Ru n n in g S p r i ng s, C A 9 2 3 8 2 •

( 9 0 9 ) 8 6 7 -7 0 3 7 • w w w. p on d o. or g

P HO NE

or disability.

Parent, Guardian or Adult Signature: _______________________________________________ Date: _____________

FILL OUT & RETURN TO YOUR GROUP LEADER.

(You should sign your own release if you are 18 years old or older)

IF YOU ARE ATTENDING CAMP AS AN INDIVIDUAL, BRING FORM TO CAMP.

Print Name: _____________________________________ Relationship to Camper: ________________________________