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PLEASE NOTE: “EARLY-BIRD SPECIAL” DISCOUNT OF $5 MAY BE TAKEN IF FORM & FEE POSTMARKED BY JUNE 1, 2002 Kamp Kiamichi 2002 Consent and Release Form (Kamp Application for Adult Counselors)
I, __________________________________________________, am of legal age, participating in the activities connected with the trip to and from and the time at Kamp Kiamichi 2002 at Robbers Cave State Park Group Camp #1 in Wilburton, OK, an activity sponsored by the Kiamichi Association of Free Will Baptists Christian Education Board from June 16, 2002 through June 21, 2002. Any medical conditions which may be relevant to a physician in the event of an emergency have been listed on the reverse of this form. I hereby give authorization to the adult kamp counselor,____________________________, who is present at Kamp, to make emergency medical decisions for me in the event that I am unable to do so for myself.
I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold the Kiamichi Association of Free Will Baptists Christian Education Board and its agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to me or my property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities.
I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Oklahoma and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto, and the terms of this release are contractual and not a mere recital.
I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE AND VOLUNTARY ACT. This is a legally binding agreement which I have read and understand.
Kamp Kiamichi carries an excess insurance policy for all kampers and counselors, which will pay any amount, including deductible, that any other policy under which the kamper or counselor may be covered does not pay. The maximum benefit amounts for this policy are:
Accidental Death - $10,000 Accident - $25,000 Specific Loss (Face Amount) - $20,000 Sickness - $2,500
Medical conditions to be aware of:
____________________________________________________________________________________
____________________________________________________________________________________
Physical restrictions:
____________________________________________________________________________________
____________________________________________________________________________________
Instructions and medications:
____________________________________________________________________________________
____________________________________________________________________________________
Is tetanus booster current?___________________________________________________________
____________________________________ Signature
____________________________________ Date My mailing address is:
_____________________________________
_____________________________________
In case of an emergency, please notify:
_____________________________________ ______________________________________ Name Relationship
_____________________________________ ____________________________________ Telephone # (Day) Telephone # (Other)
My Home Church is:___________________________________________________________________ |
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