Cross Timbers Church

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Middle School Summer Camp 2022 - Leaders on Wednesday, June 29, 2022 @ 12:00 PM

No charge

*Attendee's Date of Birth:
*Attendee's Age:
*Attendee's Gender:
*Attendee's T-Shirt Size:
*Is There An Age Group You Wish To Be Leading At Camp?:
If Yes, What Age Group Do You Wish To Be Leading At Camp?:
RELEASE, INDEMNITY AND CONSENT TO MEDICAL TREATMENT – SERVE TEAM 
*Date:
ACTIVITY/EVENT NAME - SUMMER CAMP 2022
*I am a SERVE TEAM PARTICIPANT and hereby give my full permission and consent THAT I AM PARTICIPATING in the Cross Timbers Community Church activity - hereinafter referred to as the “Activity”.  To the best of my knowledge, I AM physically fit to engage in the Activity and do not suffer from any illness, disease, injury or handicap which would hamper or impair MY participation in the Activity, or which may cause illness, disease or injury to others participating in the Activity, or which should otherwise be disclosed for purposes of this document.
*Having full knowledge and recognizing that the Activity may be dangerous, I hereby waive and release all claims owned by me, my spouse or my FAMILY and against Cross Timbers Community Church, its employees, agents, representatives, and any and all other persons engaged in or supervising the Activity, including sponsors and parents of other Participants (such persons being collectively referred to herein as the “Church Group”), which claims may arise from my participation in the Activity.  I also release and hold the Church Group harmless for any and all loss of or damage to property owned by or relating to ME OR MY family, which damage or loss arises from the care and custody of my participation in the Activity.  I agree to indemnify the Church Group for any and all claims, damages or liability resulting from MY participation in the Activity.
*In the event I should become ill or injured (and cannot speak for myself) while participating in the Activity or otherwise under the care, custody or control of Church Group, I direct any adult who shall have care, custody or control over ME TO SEEK AND authorize such adult(s) to consent to any and all medical treatment which may be deemed necessary or appropriate for the benefit of my Participant, and I specifically authorize the performing or any procedure which such adult(s) deems advisable and at the recommendation of the doctors or other health care providers who are treating ME.  I hereby waive and release all claims against any such adult(s) and the Church Group, and agree to hold each harmless of and from any and all claims or liability resulting from such decisions and/or the medical treatment of MYSELF.
*I understand and agree that if I DO NOT abide by the rules set by the Church Group or others for the Activity, or do not conduct MYSELF properly in the sole discretion of the Church Group, I will be sent home immediately, at my expense, and I will forfeit any remainder of the prepaid expenses for MY participation in the Activity.
*I understand and agree that if Cross Timbers Church does not have a background check on file within the last two years as of the last day of camp, I will be asked to submit one with the link provided by Cross Timbers Church
*This document is signed/agreed to this day and shall be effective until 1 day following the close of the event unless revoked in writing by the undersigned.
*Does the SERVE TEAM MEMBER have medical insurance coverage?:
*Medical Insurance Policy Holder Name (type NA if none):
*Policy Holder's Date of Birth:
*Medical Insurance Company (type NA if none):
*Policy/Subcriber Number (type NA if none):
*Group or other Identification Number (type NA if none):
INSURANCE CARD 

https://crosstimberschurch.org/summer-camp-insurance/
*INSURANCE CARD - I understand and agree I must provide a copy of the front & back of my medical insurance card to the Family Ministry staff.
ALLERGIES
*Please list all known allergies, food or other.  Also describe the severity of the allergy (mild, moderate, severe or anaphylactic).  If anaphylactic, does Participant carry an Epi Pen?
*Please list any dietary restrictions the participant has. (type NA if none)
*Does the participant have an inhaler prescribed to them?
MEDICATIONS
Please list any/all medications, prescriptions or over-the-counter, that the Participant is current taking or will be taking at any time during the Event.
*Medications & Dosage (enter NONE, if the participant is not taking any of the above)
EMERGENCY CONTACT INFO:
*Emergency Contact First Name:
*Emergency Contact Last Name:
*Emergency Contact Phone Number:
*Emergency Contact Relationship:
SIGNATURE
I acknowledge that I am signing this form via electronic means and hereby agree that my electronic signature shall be as binding on me as though I had originally signed the same in my own handwriting.
*Serve Team Member Signature
First and Last Name