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DSTX - Zephyr Recreation Release Form

Camp Zephyr
Recreation Release Form

The Camp Zephyr Recreation Release Form must be signed and initialed with no additions, deletions or changes, for the participant to take part in Camp Zephyr recreation activities. We want to make sure you understand the risks in these activities and have carefully thought through your willingness to participate. It is required that you read the following very carefully, make sure you understand it, and sign it on your behalf or on behalf of your minor child before participation in the activities begins.

Participant Name (please print):___ ________ Age:_ __ Gender:__ __
Address:__ ___________ City:_ ______Zip:_ ____
Home Phone:_ ____________Cell Phone:__ ________
What church/organization are you attending Camp Zephyr with? ___ __________

I understand the nature of this activity and I am qualified, in good health and in proper physical condition to participate in such activities. I acknowledge that if I believe event conditions are unsafe I will immediately discontinue participation in the activity.

Do you have any health problems or disabilities (fainting spells, asthma, heart trouble, convulsions, etc.) that may
affect your ability to participate in the Camp Zephyr recreation activities?
If yes, please explain:____ _______________________________

Please provide the following information in case of emergency:
Person to contact: ____ ______Phone:_____ ______
List of allergies, if any:___ ____________________________
Medication(s) currently taking:___ __________________
Family Physician:__ ______ Phone:__ ________
Health/Medical Insurance Carrier: __ __________Policy #:__ __

Photo Release: I am aware of the fact that photos of myself or your minor may be taken during the week by camp staff, which may appear in future camp publicity or camp website. By signing this, I give the camp permission to use these photos, aware of the fact that myself or your minor WILL NOT be identified in any such photos.

If this is unacceptable, I will so state that fact here by writing “NO” in the space provided: _____ _____

Release Of Liability Declaration: I am aware that during my participation at Zephyr, upon my request, certain risks and dangers may occur. These include, but may not be limited to the Zephyr Challenge Course and other recreation activities. I have and do hereby assume all risks and will hold staff, officers, and trustees harmless from any liability, actions, cause of action, debts, claims, and demands of every kind and nature whatsoever which I now have or which may arise from or in connection with my participation in any activities arranged for me by Zephyr and its staff. The terms hereof shall serve as a RELEASE AND ASSUMPTION OF RISK for my heirs, executors, and administrators, and for all members of family. I hereby give my authority and consent to medical treatment and surgical treatment as may be needed in the judgment of the treating physician, for my child by a physician chosen by the Zephyr Administrator or an associated employee. I understand twenty-four hour first aid is available. I further understand that limited secondary accident and illness coverage is provided. In case of an accident or illness, Zephyr will attempt to provide first aid and arrange transportation to medical services, if needed. Zephyr does have limited secondary medical insurance. Furthermore, I understand that Zephyrʼs guidelines and policies are available on their website, www.campzephyr.org, and I may access these at any time.
Initial for Release of Liability Declaration Approval: __ __

Paintball Release: The Camp Zephyr Paintball Course activity that I signed up for involves physically and emotionally demanding activities in an outdoor setting. I am aware that risk of injury from the activity and weaponry involved in paintball is significant, including the potential of permanent disability and death, and while particular protective equipment and personal discipline will minimize this risk, the risk of serious injury does exist. I understand the rules of play and will comply with all rules and regulations. I fully understand and acknowledge that risks and dangers exist in my use of paintball equipment and my participation in paintball activities. I also understand that I am financially responsible for any lost or stolen rental equipment that the above participant rents from Camp Zephyr.
Initial for Paintball Release Approval:_ __

Participant eSignature (all participants, even minors, must sign):___ _____Date:__ ___

Final Signature:
(If participant is younger than 18, final signature needs to be from a Parent/Guardian)

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February 2, 2023 1:47 pm CDT

DSTX - Zephyr Recreation Release Form Uploaded by Bridget Markwood - admin@leadernu.com IP 68.97.5.244