WHC Consent and Liability Statement

WHC Consent and Liability Statement (2023)

A Consent and Liability Statement is required to participate in an outside or overnight camp. Accident Waiver and Release of Liability

Activity Attending: *

Your Name: *
First
Last

Do you have any allergies or medical conditions?
Please list any allergies or medical conditions we need to be aware of, particularly in a medical emergency.

Health Insurance Company *
Please write None if you don't have medical insurance.

Policy or Group # *
Please write None if you don't have medical insurance.

Doctor's Name:
First
Last

Doctor's Phone:

I have read and understood: *
I certify that I'm physically well. I certify that no health-related reasons or problems preclude my participation in the trip mention above.
Please check.

I have read and understood: *
I understand that the risks associated with camp activities could result in injury. I hereby assume these risks. As a part of this activity, I understand it will be necessary to engage in travel. I hereby grant my permission for such travel. I understand that the World Harvest Church is not liable for any injuries or other occurrences due to indoor and outdoor camp activities or related risks, or the actions or omissions of WHC counselors, volunteers, employees, or any other entities being released.
Please check.

I have read and understood: *
In the case of an emergency affecting my health or welfare, the counselors, leaders, or adult chaperones have permission to administer first aid and or transport me to the nearest doctor or hospital for further emergency medical attention as deemed necessary. The individual acting in response to the emergency, World Harvest Church, and its representatives will be held blameless.
Please check.

I have read and understood: *
In an emergency, I agree to pay any necessary expenses incurred in my medical treatment, including, but not limited to, all transportation costs to and from a medical facility and, if necessary, transportation to my home or medical facility of choice.
Please check.

I certify that: *
I have read this document, fully understand its content, and agree to its terms.
Please check.

Your Name: *
First
Last

Your Email: *

Your Phone: *

Date *

Your Signature: *