Participant ApplicationThe clinic application form must be completed for each individual participating in any Just Believe event or activity. Participant's Name * First Name Last Name Participant's Date of Birth * MM DD YYYY Age * Contact Number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Is camper up to date on all immunizations? * Yes No List relevant medical history/conditions that would help us meet the student’s needs: Known Allergies Curren Medications Doctor's Name (if under medical care) First Name Last Name Doctor's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Special Instructions I have read and understand the camp rules. I agree that my child (or I) will abide by them while at any Just Believe Camp. If my child (or I) does (do) not abide by these rules, I understand that he/she/I could be sent home at my expense at the discretion of the camp director and camp administration. I also consent and give permission for the use of photographs/videos of my child (or myself) taken while at camp to be used in the promotion of Just Believe Camps. * Agree I understand that Just Believe, in which I plan to participate OR allow my child, a minor in my care to participate, involves certain risks and that regardless of the precautions taken by Just Believe the camp facility and volunteers helping with Just Believe Camp, some bodily injuries may occur. Specific risks/hazards involved in Just Believe Camp include but are not limited to the following: (1) auto accidents while traveling to and from camp activities or traveling on the camp premises; (2) dehydration; (3) physical injury sustained while participating in camp activities, many of which include livestock; and (4) medical problems such as illness, allergies, etc. * Agree In consideration for receiving permission to participate in Just Believe Camp, which is sponsored by Just Believe, I hereby release, waive, discharge, and covenant not to sue, and agree to hold harmless for any and all purposes, Just Believe, Just Believe, the camp facility, and all associated officers, servants, agents, volunteers, or employees (herein referred to as RELEASEES) from ANY AND ALL LIABILITIES, CLAIMS, DEMANDS, OR INJURY, INCLUDING DEATH, that may be sustained by me while participating in such activity, or while on the premises that is owned, leased, or controlled by RELEASEES, including travel to and from Just Believe Camp activities, and even injuries sustained as a result of the negligence of RELEASEES. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of the RELEASEES. I understand that Just Believe and the camp facility are separate legal entities. * Agree I am fully aware that there are inherent risks involved with Just Believe and I choose to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I acknowledge there may be physically strenuous activities, many of which may include livestock. I know of no medical reason why I should not participate. I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, which may be sustained by me as a result of participating in said activity including injuries sustained as a result of the negligence of RELEASEES. I further agree to indemnify and hold harmless the RELEASEES for any loss, liability, damage or costs, including court costs and attorney’s fees, which may occur as a result of my participation in said activity including injuries sustained as a result of the negligence of RELEASEES. I understand this agreement to indemnify and hold harmless does not apply to injuries caused by intentional or grossly negligent conduct. * Agree I understand that RELEASES may not maintain any insurance policy covering any circumstance arising from my participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. * Agree It is my expressed intent that this Release shall bind the members of my family and spouse if I am alive, and my heirs, assigns, and personal representatives if I am deceased, and shall be governed by the laws of the state in which Just Believe is hosted. * Agree I understand RELEASEES cannot be expected to control all of the risks articulated in this form, but RELEASEES may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required during my participation with the understanding that the cost of any such treatment will be solely my responsibility. I agree to indemnify and hold harmless RELEASEES for any costs incurred to treat me, even if a RELEASEE has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. * Agree In signing this Release, I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing agreement that has been reduced to writing have been made. I execute this document for full, adequate, and complete consideration fully intending to be bound by the same, now and in the future. I represent that I am eighteen (18) years of age or older and am otherwise competent to execute this agreement. * Agree In signing this Release, I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing agreement that has been reduced to writing have been made. I execute this document for full, adequate, and complete consideration fully intending to be bound by the same, now and in the future. I represent that I am eighteen (18) years of age or older and am otherwise competent to execute this agreement. * Agree By selecting "I agree", I verify that I have read and understand every provision of this agreement. If the participant is younger than 18 then his/her parent or legal guardian must sign where indicated below. I am the Parent or Guardian of the aforementioned minor student, and I verify by this signature the legal right to sign on behalf of the minor. * Agree Parent/Guardian in Agreeance * First Name Last Name Parent/Guardian: I hereby give my consent for the above-named student to take part in activities including arena clinics, ropes challenge course, rifle range, archery and other activities occurring within the camp program. If in the event of an emergency I cannot be reached, I hereby give my consent for camp administration or church leadership to sign for emergency medical care should it be necessary. I understand that every effort will be made to provide the safest environment possible at camp, but that accidents can and do occur. I agree not to hold liable Just Believe, the camp staff, or the camp facility in the case of an unforeseen event. * Agree Thank you!
