Philadelphia Indemnity Insurance Company Page of 1 One Bala Plaza, Suite 100, Bala Cynwyd, pa 19004



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Philadelphia Indemnity Insurance Company Page of 1

One Bala Plaza, Suite 100, Bala Cynwyd, PA 19004 11/2006
CAMP FONTANELLE PROGRAM RELEASE FORM
ALL GUESTS AND ALL PARENTS OR GUARDIANS OF ANY GUEST WHO IS A CHILD (UNDER 18) THAT WISHES TO PARTICIPATE IN ANY PROGRAM OR ACTIVITY MUST COMPLETE THE FOLLOWING PROGRAM RELEASE FORM BEFORE GUEST OR BEFORE HIS/HER CHILD MAY BEGIN THE PROGRAM/ACTIVITY.


Male

Female

Age:      

Personal Information

Participant’s Name:

                              EMAIL:                                   

Church:

     

Phone Number:

(Home): (     )       -      

(Cell): (     )       -      




Street

City

State

Zip

Address:

                                   

     

     

     

Program or Event Information

I agree for myself or for my child to participate in any Program or Event sponsored by Camp Fontanelle both on site or off site. Programs include but are not limited to: Race competitions, hiking, Zip Lines, tree climbing on rope, laser tag, archery, low ropes challenge course, jumping pillow, pony rides, hay rack rides, inflatable castles, gaga ball, corn maze, and petting barn.

RELEASE / DISCLAIMER
I do hereby assume full responsibility for any and all damages, injuries (including death), or losses that may be sustained or incurred, if any, while attending, practicing, participating or witnessing in any Activity, program, sport or physical activity occurring in or about Camp Fontanelle premises or at anY offsite location. I hereby assume full risk, waive all claims and release and HOLD Great plains united methodist camps, inc. DBA Camp Fontanelle, IT’S instructors, or partners of said program OR EVENT, individually or otherwise, harmless for any and all claims for injuries or damages.
I am fully aware and understand that Camp Fontanelle does not have on or about the premises, an employ or contract with any medical services, provisions for ordinary and/or emergency medical services.
In consideration of mine or my child’s participation in and the use of Camp Fontanelle’s facilities, I hereby release and covenant not to sue the institution, its owners, shareholders, directors, officers, employees, representatives, agents, and lessees from any and all claims resulting from any physical injury that may occur to myself or my child while participating in any program or event sponsored by Great Plains United Methodist Camps, inc. DBA Camp Fontanelle.

I have read and fully understand the above release/waiver and fully understand that I have given up substantial rights by signing this waiver voluntarily.

Parents or guardians must sign if applicant is UNDER 18.

Participant’s Name (print): _________________________________________ DATE:____________________________
Participant’s Signature: __________________________________________ DATE: ___________________________


Parent/ Guardian Name (print): ______________________________________

DATE: __________________________


Parent/ Guardian Signature: ________________________________________

DATE: ___________________________




Would you care to receive newsletters and updates of events and activities at Camp Fontanelle? YESNO
If yes, by mail or email?  MAIL  EMAIL



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