2017 Teen Winter Camp
 
2017 Teen Winter Camp
Camper's Name  * 
Camper's Email Address  * 
Camper's Address * 
Camper's Gender  * 
Camper's Age  * 
Cabin Request (Please list up to three names)
Family Physician  * 
Insurance Company  * 
Policy Number  * 
Allergies (If none, please write "Not Applicable" or "None")  * 
Special Medications or dietary restrictions (If none, please write "Not Applicable" or "None") * 
Guardian's Name  * 
I (WE) THE UNDERSIGNED PARENT(S), OR LEGAL GUARDIAN, OF THE CHILD LISTED ABOVE, A MINOR, DO HEREBY AUTHORIZE AND CONSENT TO ANY X-RAY EXAMINATION, ANESTHETIC, MEDICAL OR SURGICAL
DIAGNOSIS RENDERED UNDER THE GENERAL OR SPECIAL SUPERVISION OF ANY MEMBER OF THE MEDICAL STAFF AND EMERGENCY ROOM STAFF LICENSED UNDER THE PROVISIONS OF THE MEDICAL PRACTICE ACT
OR AND ON THE STAFF OF ANY ACUTE GENERAL HOSPITAL HOLDING A CURRENT LICENSE TO OPERATE A HOSPITAL FROM THE STATE OF CALIFORNIA DEPARTMENT OF PUBLIC. IT IS UNDERSTOOD THAT THIS
AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS, TREATMENT, OR HOSPITAL CARE BEING REQUIRED AND IS GIVEN TO PROVIDE AUTHORITY AND POWER TO RENDER CARE WHICH THE
AFOREMENTIONED PHYSICIAN IN THE EXERCISE OF HIS BEST JUDGMENT MAY DEEM ADVISABLE. IT IS UNDERSTOOD THAT ALL EFFORTS SHALL BE MADE TO CONTACT THE UNDERSIGNED PRIOR TO RENDERING
TREATMENT TO THE PATIENT, BUT THAT ANY OF THE ABOVE TREATMENT WILL NOT BE WITHHELD IF THE UNDERSIGNED CANNOT BE REACHED. THIS AUTHORIZATION IS GIVEN PURSUANT TO THE PROVISIONS OF
SECTION 25.8 OF THE CIVIL CODE OF CALIFORNIA.
Guardian signature for the statement above  * 
I HEREBY GRANT PERMISSION FOR MY CHILD TO ATTEND 2018 TEEN WINTER CAMP AT VERDUGO PINES BIBLE CAMP. I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL ACTIVITIES. I HEREBY GIVE
AUTHORITY OVER MY SON/DAUGHTER WHILE UNDER THE RESPONSIBILITY OF THE DULY AUTHORIZED WINTER CAMP WORKERS/COUNSELORS, ETC., AND PROMISE TO SUPPORT THEM IN ALL MATTERS OF DIRECTION
AND DISCIPLINE. I ACKNOWLEDGE, THAT IF DEEMED NECESSARY BY YOUTH CONFERENCE WORKERS OR CHURCH YOUTH WORKERS, THAT IF MY SON/DAUGHTER BE SENT HOME FOR DISCIPLINE REASONS OR
SICKNESS, I WILL ASSUME ALL FINANCIAL RESPONSIBILITIES AND ARRANGE FOR HIS/HER TRIP HOME. I UNDERSTAND THAT MY CHILD WILL BE TRAVELING BY CHURCH BUS TO AND FROM TEEN WINTER CAMP.
I AGREE THAT ANY CONTROVERSY OR CLAIM AGAINST FAITH BAPTIST CHURCH AND SCHOOLS, ITS EMPLOYEES OR AGENTS, OR CLAIM ARISING DURING TEEN WINTER CAMP, WHICH CANNOT BE RESOLVED WITHIN
FAITH BAPTIST CHURCH AND SCHOOLS, SHALL BE RESOLVED WITH THE ASSISTANCE OF THE CENTER FOR CONFLICT RESOLUTION THROUGH MEDIATION OR, AS A LAST RESORT THROUGH LEGALLY BINDING
ARBITRATION, ALSO BY THE CENTER FOR CONFLICT RESOLUTION. I EXPRESSLY WAIVE MY RIGHT TO FILE A LAWSUIT AGAINST FAITH BAPTIST CHURCH AND SCHOOLS, ITS EMPLOYEES OR AGENTS, EXCEPT TO
ENFORCE A LEGALLY BINDING ARBITRATION DECISION. I AGREE TO PAY LEGAL FEES FOR FAITH BAPTIST CHURCH AND SCHOOLS, SHOULD THEY NOT BE FOUND AT FAULT.
Guardian signature for the statement above  * 
AFFIRMATION OF TRUTH & CORRECTNESS YOU AGREE THAT YOUR USE OF A KEY PAD, MOUSE, OR OTHER DEVICE OR ANY SIMILAR ACT/ACTION TO (A) SELECT AN ITEM, BUTTON, OR ICON HEREIN, OR TO
OTHERWISE PROVIDE THE CHURCH WITH INFORMATION IN CONNECTION WITH YOUR COMPLETION OF THIS ELECTRONIC AUTHORIZATION FORM OR (B) MAKE ANY SELECTION REGARDING ANY AGREEMENT,
ACKNOWLEDGEMENT, CONSENT TERMS, DISCLOSURES OR CONDITIONS IN THIS ELECTRONIC AUTHORIZATION FORM, CONSTITUTES YOUR ACKNOWLEDGMENT THAT THE INFORMATION PROVIDED AND/OR THE SELECTION
MADE, AS THE CASE MAY BE, IS TRUE AND CORRECT.
Guardian initials for the statement above  * 
ELECTRONIC SIGNATURE AGREEMENT & SECURITY PLEASE SIGN THE AUTHORIZATION FORM BY ENTERING YOUR INITIALS BELOW AND BY ENTERING YOUR FULL NAME AND THE DATE IN THE BOXES PROVIDED. YOUR
TYPED NAME, DATE, AND INITIALS WILL TOGETHER SERVE AS YOUR SIGNATURE FOR THIS ELECTRONIC AUTHORIZATION FORM. THE ELECTRONIC SIGNATURE BELOW AND RELATED FIELDS ARE TREATED BY FAITH
BAPTIST CHURCH LIKE A PHYSICAL HANDWRITTEN SIGNATURE ON A PAPER FORM AS IF ACTUALLY SIGNED BY YOU IN WRITING. FURTHER, YOU AGREE THAT NO CERTIFICATION AUTHORITY OR OTHER THIRD
PARTY VERIFICATION IS NECESSARY TO VALIDATE YOUR ELECTRONIC SIGNATURE, AND THAT THE LACK OF SUCH CERTIFICATION OR THIRD PARTY VERIFICATION WILL NOT IN ANY WAY AFFECT THE
ENFORCEABILITY OF YOUR SIGNATURE OR ANY RESULTING CONTRACT BETWEEN YOU AND THE CHURCH. IF YOU DO NOT WISH TO SIGN THIS ELECTRONIC AUTHORIZATION FORM,
PLEASE CONTACT THE CHURCH OFFICE AT INFO@FAITHBAPTIST.ORG.
Guardian initials for the statement above  * 
Teen Winter Camp Cost  * 
I UNDERSTAND THAT ALL SNOWBOARDING, SKIING OR TUBING AUTHORIZATION FORMS MUST BE PRINTED, FILLED OUT AND SUBMITTED BY TUESDAY, JANUARY 2.
ALL FORMS CAN BE FOUND ON OUR WEBSITE AT HTTP://FAITHBAPTIST.ORG/WINTER-CAMP/
Guardian initials for the statement above  * 
Your Email Address  * 
Please type in the box to the right »  * 
Total $
 
 
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