Young Life Peter

GUEST CONSENT RELEASE FORM FOR OUTSIDE GROUPS USING YOUNG LIFE CAMP
NOTE TO GUEST: Young Life wants your experience at the Young Life camps to be a safe and healthy one. However, in the event of an accident or illness, it is
important that we have the following information.
Gunther. Peter. Weathington
Name_________________________________________________________________________________________________________________
Last First Middle Initial
Birthdate _______________________________
Aug 5 2011. Age ___________
11. Sex ______________
Male
Grandma & Granddad Weathington
Spouse/First Emergency Contact ___________________________________________________________________________________________
Last First Middle I nitial
13111 Laneview Court, Herndon, VA 20171
Home Address _________________________________________________________________________________________________________
Street and Number City State/Province Zip/Postal
Phone 571-239-1037.…
Home________________________________ 703-391-0950.
Business_____________________________ Cell 703-8508933
__________________
MaryBeth & AJ Gunther

Second Emergency Contact _______________________________________________________________________________________________
Last First Middle I nitial
13111 Laneview Court, Oak Hill, VA 20171
Home ________________________________________________________________________________________________________________
Street and Number City State/Provi nce Zip/Postal
Phone 571-239-1037.
Home_________________________________ HM. 703-391-0950.
Business________________________________ 804-217-4757.
Cell __________________
_
Any allergies or other medical needs?
____________________________________________________________________________________________________
Chantilly Family Pediatrics. Doctor Okonkwo
Name of Physician____________________________________________________________________________ (703) 665-2472
Phone_________________
Last First
Address _______________________________________________________________________________________________________________
24430 STONE SPRINGS BLVD UNIT 315, STERLING VA 20166-2268
☐I have had a physical within the last 24 months
TriCare Select
Medical Insurance Company________________________________ 011856609-02.
Policy #________________________ 1800-444-5446
Phone_________________
Address_____________________________________________________________________________________ Website_______________
INDEMNITY AND CONTRACT AGREEMENT: I will not hold or attempt to hold Young Life liable for any loss, damage or injury to person or property caused
by any act or neglect of other persons on or about the Property, or caused in any manner other than the willful or grossly negligent act of Young Life, its agents and
employees, and will indemnify and hold Young Life harmless from any liability for damages or claims against Young Life arising out of or in any way related to any
such loss, damage or injury.
I release Young Life, including its trustees, employees and agents, from my physical injury, including death, or illness while at the Property. 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 representatives
or assigns.
AUTHORIZATION FOR TREATMENT: I hereby give permission to the medical personnel selected by the camp director to secure and administer treatment and
to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related
transportation for the above named person.
To obtain a copy of Young Life’s Notice of Privacy Practices, log on to www.younglife.org or call (719) 867-3600.
I verify that I am or my child is in good health and am capable of participating in strenuous activities, and when necessary, will tailor my activities to those within the
bounds of my physical health.
In Colorado, campers will participate in rigorous activities at 9,000 to 14,000 feet. I recognize that any medical treatment and/or medical transportation that is provided
to me or my child while attending a Young Life camp will be paid for by my medical insurance company.
Canada: Malibu Club/Beyond Malibu: I agree that any complaint, demand, dispute, claim involving bodily injury including death and/or personal injury or cause of
action arising out of or in any way related to Young Lie’s Malibu Club or Beyond Malibu, including any activity, event, medical treatment, and/or transportation will
be governed by the laws and jurisdiction of the Canadian Province where the event or incident occurred.
COVID-19: I recognize that a national emergency was declared because of the COVID-19 outbreak and that different states and/or counties/cities may be in various
states of emergency. I recognize that even if Young Life has taken reasonable actions in light of COVID-19 and other coronaviruses, there is no guarantee that me or
my child will not contract/transmit COVID-19 or other infectious or contagious illnesses or diseases while participating in activities and events at the Young Life
property/camp, or traveling to and from, Young Life’s camp property and I release Young Life in the event of such an occurrence.
The Center for Disease Control ( CDC) has identified that certain individuals are at Higher Risk for Severe Illness if they become ill with COVID-19. This includes
those who have chronic lung disease, moderate/severe asthma, a serious heart condition, are immunocompromised, or have severe obesity, diabetes, or chronic
kidney/liver disease or who are over the age of 65. Based on the CDC’s High-Risk criteria, you have determined if you want to participate in this event or if you want
your child to participate in this event.
WAIVER AND RELEASE
If I am under the age of 18, or under the age of 19 if attending Malibu Club or Beyond Malibu, my parent or guardian, by signing below, also consent 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 representatives and assigns.
My parent or guardian also promises, by signing below to defend, indemnify and hold Young Life harmless from any claim asserted by me against Young Life,
including its trustees, employees and agents, if I should repudiate this release after obtaining adulthood.
Signature__________________________________________________________________________ March 2 2023
Date___________________________
TFCA
Name of Your Group/Church_________________________________________________________ March 3-5th 2023
Dates of Event______________________
YL-6009 (November 2021) Printed in U.S.A.

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GUEST CONSENT RELEASE FORM FOR OUTSIDE GROUPS USING YOUNG LIFE CAMP

MaryBeth & AJ Gunther

YL-6009 (November 2021) Printed in U.S.A.

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