Print this out, Fill it out and Give it to the Youth Staff

Name: _____________________________________________________________

Current Grade (before May 30th)____ Age___  M  F    School_______________

Address:____________________________________________________

City:____________________________________

Zip: _________________

Phone:_________________________

Cell Phone:_______________________

Email Address____________________________________________

Parent's Name:__________________________

Parent's Email_______________________________

Emergency Contact__________________________ Relation ___________________

Emergency Phone__________________________

Parent's Signature____________________________________________

________________________________________________________________________

RELEASE AND CONSENT TO MEDICAL TREATMENT

STATE OF TEXAS

COUNTY OF COLLIN

I do hereby consent as parent or legal guardian of ________________________________to reasonable and necessary medical treatment in the event of the necessity therefore, and I hereby authorize the First Baptist Church of McKinney, through its employees, agents and volunteers, to provide such consent to any health care provider that may require it, sign necessary papers, and in general arrange for reasonable and necessary medical care and treatment that may be necessary.

            I further release and forever discharge the First Baptist Church of McKinney, its employees, agents and volunteers of and from any and all claims, demands, damages, actions, causes of action, negligence or suits of any kind or nature, whether heretofore or hereafter accruing, and whether not known, arising out of any activity of the First Baptist Church of McKinney in which my child is a participant.

              This Release and Consent shall be valid and binding until revoked by me, in writing, delivered to Grant Byrd, First Baptist Church of McKinney, Texas.  I acknowledge that I have read and understand the effect of this Release and Consent to Medical Treatment, and I am executing it for the purposes and considerations set forth.

_______________________________

Parent or Guardian

Dated this __________ day of _______________, _20______.

Insurance Information:

Carrier: ________________________________________________

Group Number: _________________________________________

Policy Number: _________________________________________

Telephone number of Insurance Company: ___________________

Xtreme Camp

Contact Form

Name:

Last _____________      First ________  Middle _____

Age: ____                Date of Birth  ___________

Male  ___     Female  ___          

Address:     ________________________________

                         City _____________  St. ___  Zip ______

Parent or Guardian Name: ______________________­_

Phone:   Home  _____________   Work ____________     

                         Cell    _____________

Any special requirements or attention needed:__________

_________________________________________

Health related information:_______________________

_________________________________________

Dietary restrictions:___________________________

Current medication (send with instructions): __________

_________________________________________

Reason for taking above medication: ________________

_________________________________________

Walk on Water

Agreement to Participation

Assumption of Risk and Release of Liability

PLEASE READ BEFORE SIGNING

The undersigned acknowledges that during the session that the applicant has requested to participate in,

Certain risks and danger may occur.  The undersigned recognizes that such risks and danger may include

Loss or damage to personal property, physical or psychological damage and/or injury, not excluding fatality due to accident.  I certify that I am completely healthy (both physically and emotionally) and capable of participating in this session.  I have listed on the medical information form medical conditions

That WALK ON WATER Inc. should be aware of which may hinder my participation in the session.

However, I understand that it is solely my responsibility to determine whether there is any medical reason

That I should not participate in the session and to obtain approval for any and all activities from the appropriate

Health-care providers.  The health history is correct as far as I know, and the person herein described has permission

To engage in all prescribed camp activities except as noted.  I hereby authorize the medical personnel selected by

The camp director and/or church leader to order x-rays, routine tests, treatment, and necessary transportation for

Me/my child as deemed necessary.  I, individually and on behalf of the minor and all other family members,

Executors or administrators, do hereby release, forever discharge, and agree to hold blameless WALK ON WATER

Inc. and its counselors, staff, employees, agents, and lessors from any and all liability, claims, INCLUDING, BUT

NOT LIMITED TO THE NEGLIGENCE OF WALK ON WATER Inc. STAFF, DIRECTORS, COUNSELORS,

EMPLOYEES, AGENTS and LESSORS, or demands for personal injury, sickness, or death, as well as property

Damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant

While said person is participating at WALK ON WATER.  In consideration of, and as part payment for, the

Right to participate in such a program and the services arranged for me by WALK ON WATER Inc.  its staff,

Directors, counselors, employees, agents and lessors, from any and all liability, actions, causes of action,

INCLUDING BUT NOT LIMITED TO THE NEGLIGENCE OF WALK ON WATER INC DIRECTORS,

COUNSELORS, EMPLOYEES, AGENTS and LESSORS, debts, claims, and demands of every kind and nature

Whatsoever, whether for bodily injury, property damage or loss otherwise, which I now have or which may arise

From or in connection with my program or participation in any other activities arranged for me by WALK ON

WATER Inc. its staff, directors, counselors, employees, agents, and lessors, for all members of my family,

Including any minors accompanying me.  I SPECIFICALLY AGREE THAT MY AGREEMENT TO INDEMNIFY

AND HOLD HARMLESS WALK ON WATER INC. ITS STAFF, DIRECTORS, COUNSELORS, EMPLOYEES,

AGENTS and LESSORS, INCLUDES ALL LITIGATION COSTS AND ATTORNEY FEES FOR ANY

LITIGATION BROUGHT ON BY MYSELF, ON BEHALF OF THE MINOR, IF APPLICABLE, OR ANY

OTHER FAMILY MEMBER. I grant permission to WALK ON WATER to use photographs and any video taken by WALK ON WATER for use on web sites or other electronic form or media, without notifying me.  I hereby waive any right to inspect or approve the photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photographs. I hereby agree to release and hold harmless WALK ON WATER, via electronic or media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any re-use, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in production of the finished product. I also state that I am not under, and will not be under the influence of any

Chemical substance including alcohol.  I fully understand that my physical activity involves risks of injury.

I also understand that my participation in this WALK ON WATER Inc. program is entirely VOLUNTARY.

I enter into this session and take full responsibility for my decision to participate or not to participate and agree

To follow all safety instructions.

____________________________________   ___________________________________   _________________

Name of Participant (please print)                      Signature of Participant                                   Date

                                                                           (If under 18, parent or guardian must sign)

_____________________________________   ________________________

Signature of Witness                                            Date