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Medical Information:
Personal Information:
Talent Show/Music:
Liability Releases, Medical Coverage and Acknowledgment of Camp Standards for CAMPERS:

Assumption of Risks and Liability Releases:
In exchange for participation with the Church of GodAssembly (CGA) camp program, I agree and covenant for myself and my minor child (along with any respective heirs, assigns, and legal representatives) to indemnify, hold harmless and defendCGA against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my child's use of or presence or participation with the CGA camp program. I recognize there are certain inherent risks associated with camp participation and I assume full responsibility for personal injury, and further release and discharge CGA for any injuries, loss or damage arising out of my or my child's use of or presence or participation with the CGA camp program, whether caused by the fault of myself, my child, CGA or other third parties. The undersigned acknowledge that participation with the CGA camp program poses a risk of bodily injury, illness or death. Camp activities may include, but are not limited to, basketball, volleyball, softball, soccer, flag football, swimming, water skiing, archery, riflery, and campus improvement tasks in addition to other recreation, travel, meals and lodging.
Medical Authorization:
In the event of an injury to my minor child as a camp participant during the above-described activities, I give my permission to CGA and/or to the employees, representatives or agents of CGA to arrange for all necessary medical treatment for my child, for which I shall be financially responsible. CGA shall have the following powers with respect to medical treatment: (1)The power to seek appropriate medical treatment or attention on behalf of my child as may be required by the circumstances, including without limitation, that of a licensed medical physician and/or a hospital; (2) The power to authorize medical treatment or medical procedures in an emergency situation; and (3) The power to make appropriate decisions regarding clothing, bodily nourishment and shelter. This temporary authority will be in place and remain in effect for the duration of the camp session (including in connection with any CGA-provided transportation to and/or from camp facilities that may be necessary immediately before and/or after the camp session) unless such authority is terminated in writing prior thereto.

Medical Insurance Coverage Information:

All camp participants shall fully be responsible for providing for their own medical coverage and I accept, for myself and my minor child, full financial responsibility for any necessary medical treatment related to camp participation. Medical insurance coverage information must be provided below. If no medical insurance coverage is in place, writeSELF INSURED on the Insurance Company Name line.

Emergency Contact Information
Privacy Release:

Each of the undersigned grants CGA the irrevocable right to use his or her name, picture, or photograph in any CGA publications and web sites without compensation and without prior approval of the finished version, and to use any written copy that may be created in connection with CGAs camp program.

Parent/Guardian Consent:

The undersigned parent(s)/guardian(s) consent to the participation ofthe undersigned minor child with the CGA camp program and agree on behalf of the undersignedminor child to all of the terms and conditions of this Agreement. By signing this Agreement, Irepresent that I have legal authority over and custody of the undersigned minor child as theApplicant. I hereby warrant that my child is physically and mentally capable of participating in theCGA camp program.

Applicable Law & Venue: This entire agreement is to be regulated by, and interpreted exclusively according to, the Laws of the State of Kansas. *

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