My ACF Community
First Time Here
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Pre-K & Kinder
What is Baptism?
What Can I Expect at My Baptism?
What Do I Need to Do to Be Baptized?
Infant Baptism and Dedications
Baptism Class Form
ACFkids Spring Retreat Medical Release 2020
ACFkids Spring Retreat Medical Release 2020
You will need your medical insurance info and the date of last tetanus shot in order to complete this form. We recommend gathering this info before you begin.
Participant Last Name
Date of Birth
In case of an emergency notify
Name & Phone
Relationship to participant
Generally, the participant's health is
If Fair or Poor, please explain the condition
List any medical difficulties which you are currently experiencing or for which you are currently being treated
List any medications you are currently taking
List any medicines or substances to which you are allergic
Date of last tetanus immunization
Do you have medical insurance?
Primary policyholder's name
Permission, Acknowledgements, Release, Indemnity
Please check each box to signify your agreement and understanding
This form must be submitted by all spring retreat attendees. I certify that I am either an adult (eighteen years or older) completing this form on my own behalf, or I am the adult parent/guardian of a minor who will be attending or serving as a leader at the retreat. If submitting on behalf of a minor, I have discussed the risks with him/her, and he/she understands and accepts them.
If an individual requires medical attention while participating in an event, the individual is responsible for the cost. If the medical attention is needed because of an accidental injury at the retreat, Pine Cove provides a limited insurance policy that applies to those costs.
My permission is granted for the retreat or event director, church official, any retreat or event staffer, or adult present or in charge of first aid, to obtain necessary medical attention in case of sickness or injury to me or my child.
Retreat attendees may be involved in a variety of activities, including, but not limited to, bus transportation, swimming, boating, hiking, barn swing, zip line, campfire, sports, and other active group games. In addition, the retreat environment, including its terrain, waterfront, natural and man-made structures, and insects, snakes, or other wildlife, can cause harm.
Retreat activities, whether or not supervised, can cause loss or damage to property, personal injury (physical and emotional), and in some cases, even death. Specific risks include, but are not limited to, insect induced injuries, diseases, or allergic reactions; exposure to extreme weather; burns; drowning; head injuries; broken bones; or, uncomfortable group dynamics. Retreat attendees participate at their own risk, and except for gross negligence and intentionally wrongful conduct, Austin Christian Fellowship and Pine Cove are not responsible for any loss which an attendee may suffer while at the retreat or while travelling to and from.
I release Austin Christian Fellowship, Pine Cove, the church, retreat or event sponsors and their employees and volunteers ("Released Parties") from, and agree not to sue them for, any claim which I or the minor may have for injury, death or other loss incurred during or in any way related to my or the minor's retreat attendance.
I agree to indemnify (that is, to defend and protect, including by paying liabilities, costs and attorneys fees) Released Parties from any and all claims which I, the minor, a member or my or the minor's family, or any other person, may have for any injury, death or other loss incurred by or caused by me or the minor, related in any way to my or the minor's retreat attendance. This acknowledgement and assumption of risks and agreements of release and indemnity include losses and claims arising in whole or part from the negligence, but not the gross negligence or intentionally wrongful conduct, of a Released Party.
I give my consent and permission for the taking of photographs and/or video of me (or my child) during normal retreat or event activities and waive and/or assign any and all rights (including copyright) of such media to Austin Christian Fellowship (ACF). ACF, as the sole owner of such media shall have the exclusive right to control and determine the use, display, performance, reproduction and dissemination of any such photographs and/or videos.
Please type your full name, which will serve as your signature on this form.
If you are human, leave this field blank.