2016 Adult Release and Waiver of Claims Form Individual InformationGroup*Cabin (if known)Name* First Last Age*Email* Phone*College Attending This Fall (if applicable)Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code In Case of Emergency InformationName* First Last Relationship*Home Phone*Cell or Work Phone*Secondary Emergency InformationName* First Last Home Phone*Medical InformationDo you have any known allergies or are you unable to take any medication?*YesNoIf yes, what?*Do you presently take any medications regularly?*YesNoIf yes, what medications?*For what reasons?*List any other medical condition(s) that would be helpful to know about:Date of last tetanus immunization?* The above named adult has current medical insurance coverage through:Insurance Company*Name on Insurance Policy* First Last Insurance Company Phone Number*Insurance Company Policy Number*Does your insurance company require notification prior to emergency health care at a hospital?*YesNoIf yes, Phone Number:*It is your responsibility to obtain insurance permission for treatment.Release and Waiver of ClaimsI will be coming to Falls Creek. Falls Creek Baptist Conference Center is managed and operated by the Baptist General Convention of Oklahoma (“BGCO”). In the event that I should need emergency medical care or attention, the BGCO or any one of its agents or employees is hereby authorized to provide such emergency medical care, including without limitation, medical, dental, surgical care or hospitalization, to me as is recommended or suggested by a physician, nurse, or other health care professional. If such emergency care is provided, I understand that my health insurance information will be given to the health care professional and that any expenses not covered by my insurance shall be my responsibility. I understand that the BGCO will not be obligated to pay either the health care professional or me for any medical expenses incurred. There are instances when third party contractors are used to operate and supervise various events and activities. In those instances where third party contractors are used, I agree that the BGCO is not responsible for the action of these third party contractors. I further agree that the BGCO is also not liable for the actions or activities of participants or sponsors participating in events or activities operated by third party contractors. I understand that the risk of injury from any recreational activity is significant, including, but not limited to, the potential for permanent paralysis and death. While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist. I knowingly and freely assume all risks, both known and unknown, even if arising from negligence, and assume full responsibility for my participation and observing of such recreational activity. Furthermore, in consideration of being allowed to attend Falls Creek, I hereby waive any and all causes of action, rights, claims or suits which I may have against the BGCO, its agents or employees as a result of injury to me, including, but not limited to: (1) injuries arising from participation in or observation of recreational activities at Falls Creek, and (2) injuries arising from the decision of the BGCO or its agents or employees to consent to the provision of emergency medical care to me. I understand that my image may be included in a video or in photographs that may be made at Falls Creek. I understand that a promotional or highlight video may be available for sale from Falls Creek. I consent that my image may appear on videos, promotional resources, camp endorsed web sites, etc. I give authority and permission to the BGCO, its employees or its agents to inspect my belongings while at Falls Creek. Signature*Today's Date* Must be 18 years old or older to sign this form. Please make a copy of this form for all adults attending Falls Creek. Every adult attending Falls Creek must fill out this Release Form and turn it in on the first day at registration.