CONTINUED ON BACK SIDE. STUDENTS WILL NOT BE ADMITTED WITHOUT FORM

COMPLETED AND SIGNED BY PARENT/GUARDIAN AND STUDENT ON BACK SIDE.

FILL OUT BOTH SIDES OF THIS REQUIRED HEALTH, CONSENT AND RELEASE FORM COMPLETELY

First Name Last Name Birth date / / Gender Age Grade Parent or Guardian(s) Home Address, City, State, ZIP School Home Phone: Student phone if applicable: Health History (give approximate dates) Diseases/Allergies (date not needed) Allergies (date not needed) Frequent Ear: Chicken Pox Hay Fever: Heart Defect/Disease: Measles Ivy Poisoning: Diabetes: German Measles Insect Stings: Bleeding/Clotting Disorder: Mumps Penicillin Hypertension: Hepatitis A Other Drugs Mononucleosis: Hepatitis B Asthma Convulsions: Hepatitis C Other (Specify) Operations or serious injuries with dates: Chronic or recurring illness or medical condition: Current medications: Other Diseases or behavioral considerations if applicable:

Open to all MIDDLE SCHOOLERS. Cost is $20 + cash for concessions. Bring money or check

made to Campus Life and this form to pickup location. We’ll be picking up students in buses at

10PM @ ********* on Fri, May 8th and transporting them to multiple locations including The

Willamalane Center, Skate World and First Baptist Eugene. We will have the students back at

7:00AM on Saturday. FOR MORE INFO CONTACT ****** @ ************

OPEN ONLY TO MIDDLE SCHOOLERS - CONSENT FORM REQUIRED DROP OFF STUDENTS ONLY AT DESIGNATED PICKUP LOCATION

NO BACKPACKS OR LARGE BAGS ARE PERMITTED SMALL BAGS WITH FOOD OK - CONCESSIONS WILL BE OFFERED

DANCE PARTY ● VIDEO GAME WALL

DODGEBALL ● BASKETBALL ● ROLLER SKATING

THE INFLATABLES and MUCH MORE!

FRIDAY, MAY 8th — MEET @ *************** @ 10PM

iPOD GIVEAW

AY

CAMPUS LIFE IS A PROGRAM OF YOUTH FOR CHRIST AND NOT AFFILIATED WITH ANY SCHOOL.

FOR MORE INFO VISIT LCYFC.ORG - 1190 W 7TH AVE, EUGENE, OR 97402 - 541-686-9225

Name of Family Physician if applicable:____________________________________________________ ACCIDENT COVERAGE I understand that my personal insurance will be primary for student accidents and that Youth for Christ’s insurance is secondary up to a maximum limit. Youth for Christ will coordinate payments for deductibles and co-pays. Youth for Christ’s policy does not cover student illnesses. My Insurance company if applicable Policy Number(s) if applicable Insurance company address � Not currently Insured. Youth for Christ reserves the right to subrogation if it is later determined that personal medical insurance was in place. This health history is correct as far as I know, and the person herein described has permission to engage in all camp/retreat activities except as noted. AUTHORIZATION FOR TREATMENT: I hereby give permission to the medical personal selected by the event director to order X-rays, routine tests, treatment, to maintain and/or release any medical records necessary for insurance purposes and to provide or arrange necessary related transportation for me or my child. In the event I cannot be reached in an emergency, I hereby give permission to the licensed medical provider selected by the event director to secure and administer treatment, including hospitalization, for the person named above. As my attendance at a Youth for Christ camp/retreat is a privilege, I release Youth for Christ, including its trustees, employees and agents, from my physical injury, including death, or illness while at camp/retreat, including my Youth for Christ sponsored travel to and from camp/retreat, in consideration of this privilege. I recognize and understand that there are inherent risks associated with many camp/retreat activities. I will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representative or assigns. If I am under the age 18, my parent or guardian, by signing below, also consents to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representative or assigns. My parent or guardian also promises, by signing below to defend, indemnify and hold Youth for Christ harmless from any claim asserted by me against Youth for Christ, including its trustees, employees and agents, if I should repudiate this release after obtaining adulthood. I also understand that illegal or immoral activities will result in the student being sent home immediately. (These activities would include but not be limited to the possessions and/or use of drugs or alcohol, bringing any illegal substance or material to event, sex outside of marriage relationship, stealing, fighting, defiance, lying about age, etc) I also understand that students are not allowed to leave without parent checking students out of facility. If students are found attempting to leave without permission, students will be sent home immediately. I also understand that Youth for Christ will not be responsible for any lost or stolen items. Bag Check will not be offered. Large bags and backpacks are not permitted. We highly recommend that students don’t bring valuable items that could be stolen. We will not be responsible for lost or stolen items. I release all rights of any video, photo or other media source materials taken of my child for the exclusive use of Youth for Christ.

CAMPUS LIFE IS A PROGRAM OF YOUTH FOR CHRIST AND NOT AFFILIATED WITH ANY SCHOOL.

FOR MORE INFO VISIT LCYFC.ORG - 1190 W 7TH AVE, EUGENE, OR 97402 - 541-686-9225

CONTINUED FROM OTHER SIDE

SIGNATURE OF PARENT/GUARDIAN DATE SIGNATURE OF STUDENT DATE

November 6-8, 2015

�HUGE LAKE FRONT PROPERTY �BON-FIRE CAMPUS LIFE STYLE �SHOPPING IN SISTERS, OR �AND TONS MORE!

SPACE IS LIMITED! GET YOUR $25 DEPOSIT IN TO HOLD YOUR SPOT!

We will be picking up students at ******* on October 4th at ****.

We will return by 7PM October 6th. We will be staying at Big Lake

Youth Camp located at 13100 Hwy 20, Sisters, OR.

Campus Life is a program of Lane County Youth For Christ,

1190 W 7th Ave, Eugene, OR 97402

+ FOOD MONEY ON THE ROAD

$69

Register at www.lcyfc.org

FOR MORE INFO, CONTACT ****** @ ************