Adult Release Of Liability And Medical Consent Form (Page 2 of 2) in pdf

a ministry of The Free Methodist Church in Southern California

Adult Release of Liability and Medical Consent Form

Page 2 of 2

List all medical conditions: physical, emotional, behavioral disorders and learning disabilities.

___________________________________________________________________________________________________________

Please list ALL allergies: Drug ________________________________ Insect/Plant ___________________________________

Food _______________________________ Diet Restrictions _______________________________

List medications Camper will require while at camp and reason for taking the medicine.

____________________________________________________________________________________________________________

By signing this form I give my informed consent to the First Aid personnel assigned by OGCCC who are certified in a

minimum of CPR and First Aid by a nationally recognized provider to provide basic First Aid and comfort measures through

standardized camp treatment procedures, which includes the use of over-the-counter medications. I understand that it is my

responsibility to make arrangements for a guest with greater healthcare needs than the First Aid personnel can provide within

their individual certifications, licenses and scopes of practice. I authorize OGCCC to arrange for or provide any necessary

related transportation to the nearest medical facility for urgent or emergency medical treatment if indicated, and I do assume all

responsibility for payment for such treatment. I hereby give permission to the physician selected by OGCCC to secure and

administer any and all medical treatment deemed necessary for me, including hospitalization. This completed form may be

photocopied for trips away from OGCCC’s properties.

I authorize the use of the following generic, over-the-counter medications as directed by the labels provided by the

manufacturer: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray,

anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped

skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic

balms and gels, with the exception of ________________________.

I authorize OGCCC to allow myself to participate in any and all activities that may include but are not limited to those

outlined in the camp brochure and/or web site. As a condition of receiving this benefit, I do hereby agree to the following: I

understand that my participation in these activities can expose myself to dangers both from known and unanticipated risks.

Acknowledging that such risks exist, I on behalf of myself and any other party who may have the right to assert any rights for or

on my behalf, do hereby forever release and discharge, indemnify and hold harmless The Free Methodist Church in Southern

California and their Oak Glen Christian Conference Center, its affiliates, officers, directors, agents, employees, insurers,

successors in interest, attorneys, or any other person or persons associated with any or all of them who might be liable (the

“Released Parties”) from and against any and all claims, causes of action, actions, suits, demands, losses, damages,

expenses, costs or liability (collectively, “Losses”) arising from or in connection with my participation in OGCCC’s camp and its

activities, including Losses arising from the negligence of any of the Released Parties, whether such Losses arise in connection

with bodily injury (including death), property damage or otherwise (collectively, the “Released Claims”). The Released Claims

include Losses arising out of any condition of the premises at which the camp activities are held or the conduct of any person

in connection with the preparation for, supervision of, or conduct of any activity, whether planned or unplanned. I further

understand and acknowledge that I make this release in full accord and all Released Claims.

I represent and acknowledge that I have read and understand this form and the release granted above and warrant

that all statements made herein are true to the best of my knowledge. I have read and understand this entire form and the

release granted above and warrant that all statements made herein are true to the best of my knowledge. I have read and

understand this entire form and by signing below agree to the terms herein.

Signature ___________________________________________________________

Date ______________________________

PO Box 1580, Wildomar, CA 92592

909-797-2570

Adult Release Of Liability And Medical Consent Form Page 2

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