Register Parental Consent Cross Roads Release of Liability for Minors I, the undersigned, am the parent or legal guardian of _____________________________ (minor’s name) and I am voluntarily allowing ______________________________ (minor’s name) to participate in a retreat sponsored by The Capital District of UMC on June 27-July 1, 2016; at the Cross Roads Retreat and Conference Center Inc., a Texas non-profit corporation. I understand and agree that ____________________________ (minor’s name) will be participating in a program and residing at the camp facility where the program is held. In consideration of the service, training, transportation and accommodations provided to me by the participants, directors, officers and members of The Capital District UMC, I hereby release the Cross Roads Retreat and Conference Center Incorporated and its officers, directors, members, volunteers and participants from any and all liabilities, claims, causes of action or damages which I might claim for injuries or damages suffered or sustained by ________________________________ (minor’s name) during or after the event. This release is binding on me and my heirs, devisees, and legal representatives. I further authorize an adult, designated by Son Days Camp, in whose care the minor has been entrusted, to consent to any medical treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any licensed physician. I agree to be liable and agree to pay all cost and expenses incurred in connection with such medical services. I also give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in the above event. In no way shall I hold the Cross Roads Retreat and Conference Center, Inc., Capital District UMC or Rio Texas Annual Conference of the United Methodist Church and its representatives accountable for any injury and/or subsequent expense incurred by the participant By signing below, I acknowledge and accept the risks of injury associated with participation. Date_____________________________________ Signature_________________________________ Printed Name_____________________________ June 27 – July 1, 2016 Summer Overnight church Camp At Cross Roads Retreat in Caldwell, Texas for children entering 3-5 th grade Camper Name:_______________________________ Birth Date:___________Male: □ Female: □ Grade:_______ Camper T-shirt size: □ Child Small □ Child Medium □ Child Large □ Adult S □ Adult M Permission to use child photo for media or Facebook “Son Days Camp 2016” Group: Yes or No You may request to join the private Facebook Group: “Son Days Camp 2016” to follow camp activities during the week of camp. Home Phone:________________________ Camper Cell Phone:__________________ Parent Name:________________________ Email:______________________________ Parent Cell Phone: ____________________ Address:_____________________________ City:________________________________ Zip:____________ Allergies:_____________________________ _____________________________________ Medication (prescription and over the counter medications must be labeled and checked into camp nurse upon check in): _____________________________________ _____________________________________ _____________________________________ Insurance Company____________________________ Name of Primary Insured________________________ Group Policy #__________________ Social Security # of Primary Insured_________________________ Chronic/Acute Illness:_______________________________ _____________________________________ Persons to notify in case of emergency: 1.Name:_____________________________ Relation:____________________________ Phone:______________________________ 2.Name:_____________________________ Relation:____________________________ Phone:______________________________