2016 Child Release and Waiver of Claims Form Individual InformationGroup*Cabin (if known)Participant Name* First Last Age*Grade this fall:*Student Email* Phone*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 InformationDoes participant have any known allergies or are you unable to take any medication?*YesNoIf yes, what?*Does participant 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?* Date Format: MM slash DD slash YYYY The above named child 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 the responsibility of your child’s group leadership to obtain insurance permission for treatment or to limit your child’s recreational activities because of a stated medical condition.Release and Waiver of ClaimsMy child will be coming to Falls Creek. Falls Creek Baptist Conference Center is managed and operated by the Baptist General Convention of Oklahoma (“BGCO”). I will not be coming to Falls Creek with my child. In the event that my child should need emergency medical care or attention, the BGCO or any one of its agents or employees is hereby authorized to consent to the provision of such emergency medical care, including without limitation, medical, dental, surgical care or hospitalization, to my child as is recommended or suggested by a physician, nurse, surgeon or other health care professional. If such emergency care is provided to my child, I understand that my child’s health insurance information will be given to the health care professional and that any expenses not covered by my child’s 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 on behalf of my child. 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 child’s participation and observing of such recreational activity. Furthermore, in consideration of my child being allowed to attend Falls Creek, I, on behalf of myself and my child, hereby waive, and I hereby agree to indemnify and hold harmless the BGCO, its agents or employees, against any and all causes of action, rights, claims or suits which I or my child may have against the BGCO, its agents or employees as a result of injury to my child, including, but not limited to: (1) injuries arising from my child’s 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 my child. I understand that my child’s 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 child’s image may appear on videos, promotional resources, camp endorsed web sites, etc. I give authority and permission to the BGCO, its staff or its agents to inspect my child’s belongings while at Falls Creek. I understand that Falls Creek is a place where many students seek counsel and advice from adult leaders, staff, counselors and others. I hereby consent to my child receiving spiritual and emotional counsel during their time at Falls Creek. I have received and read the Parent Information about Falls Creek including the list of the recreational options and I have received satisfactory answers to all my questions about such information. Signature*Relationship to child*Today's Date* Date Format: MM slash DD slash YYYY All students attending Falls Creek must have a parent fill out this release form and turn in this release form on the first day at registration.