iPOD GIVEAWAY

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

DANCE PARTY VIDEO GAME WALL

DODGEBALL BASKETBALL ROLLER SKATING
THE INFLATABLES and MUCH MORE!
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. Well 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
FILL OUT BOTH SIDES OF THIS REQUIRED HEALTH, CONSENT AND RELEASE FORM COMPLETELY
First Name
Gender

Last Name
Age

Grade

Birth date

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

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

CONTINUED FROM OTHER SIDE

Name of Family Physician if applicable:____________________________________________________
ACCIDENT COVERAGE
I understand that my personal insurance will be primary for student accidents and that Youth for
Christs insurance is secondary up to a maximum limit. Youth for Christ will coordinate payments for
deductibles and co-pays. Youth for Christs policy does not cover student illnesses.

November 6-8, 2015

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.

HUGE LAKE FRONT PROPERTY

BON-FIRE CAMPUS LIFE STYLE

SHOPPING IN SISTERS, OR

AND TONS MORE!

69

+ FOOD MONEY ON THE ROAD

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.

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 dont
bring valuable items that could be stolen. We will not be responsible for lost or stolen items.

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

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.

Register at www.lcyfc.org
SIGNATURE OF PARENT/GUARDIAN

DATE

SIGNATURE OF STUDENT

DATE

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

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

1190 W 7th Ave, Eugene, OR 97402