Fall Weekend Registration Form
This year we are going to Young Life's beautiful Windy Gap camp which is located in Weaverville, NC, just north of Asheville!  Because the public schools have Monday off of school, we are leaving for camp on Saturday morning and returning on Monday night.
Sign in to Google to save your progress. Learn more
Student's First Name *
Student's Last Name *
Student's Birthdate *
MM
/
DD
/
YYYY
Student's Sex *
Student's School *
Parent/Guardian's Name(s) *
Parent/Guardian's Phone Number *
Parent/Guardian's Email *
Home Address *
Emergency Contact Name *
Emergency Contact Phone Number *
Please describe any allergies or medical needs: *
Name of Physician *
Physician's Phone Number *
Medical Insurance Company *
Insurance Policy Number *
Parent Signature for Indemnity and Contract Agreement *
I will not hold or attempt to hold Young Life liable for any loss, damage, or injury to person or property caused by any act or neglect of other persons, or caused in any manner other than the willful or negligent act of Young Life, its agents and employees, and will indemnify and hold Young Life harmless from any liability for damages or claims against Young Life arising out of or in any way related to any such loss, damage or injury. I release Young Life, including its trustees, employees and agents, from me or my child’s physical injury, including death, or illness while at the activity. I/We will assume the risk associated therewith, whether known or unknown to me/us at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.
Parent Signature for Authorization for Treatment *
I/We hereby give permission to the medical personnel selected by Young Life to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person. To obtain a copy of Young Life’s Notice of Privacy Practices, log on to www.younglife.org or call (719) 381-1950. I verify that I or child named above is in good health and capable of participating in strenuous activities and, when necessary, will tailor my/their activities to those within the bounds of my/their physical health. I recognize that any medical treatment that is provided to me (or my child) while attending a Young Life activity will be paid for by my medical insurance company and guarantee payment for services not paid by insurance. Young Life provides SECONDARY insurance for accidents in the amount of $20,000 medical, $4,000 dental. Claims less than $250 are covered in full by Young Life. I hereby grant Young Life permission to use, reproduce, and/or distribute photographs, films, video and sound recordings of me or my child without compensation or approval, for use in materials created for purposes of promoting the activities of Young Life, including the Internet.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms