CCUC Teen Camp 2019

Camper Registration Information

First Name *

Last Name *

Date of Birth (##/##/####) * +

Gender *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Is this the campers first time attending Teen Camp? *

Grade Just Completed *

Church That Camper or Friend Attends

Emergency Contact Information

In the event of an emergency, who should we contact?

Name *

Phone Number *

Relationship to Camper *

Transportation to Camp

Will the camper require bus transportation to camp? *

If "Yes," from:

Special Needs or Medication(s)

Please list any medications the camper is taking and any allergies or dietary needs that he/she may have.

Health Insurance Information

Plan Company and/or Name

Member ID

Group Number

Consent Forms

Chinese Christian Union Church
Teen Camp 2019 – Consent & Emergency Release

As parent/legal guardian of

Camper Name

(the “Participant”), I grant permission for my child to attend Teen Camp on August 5-10, 2019. I have read the attached information about the activity and understand that my child will be at Lake Geneva Youth Camp and Conference Center in Wisconsin under the supervision of the adult staff.

I have read the above information about the trip and understand that my child will be leaving the Chinese Christian Union Church (CCUC) premises.

I acknowledge that participation in the activity described above involves risk to the Participant (and to the Participant’s parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage.

In consideration for the opportunity to participate in the activity described above (the “Activity”), the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the Activity. The Participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the Activity or during transportation to and from the Activity, as well as for any medical treatment rendered to the Participant that is authorized by the Sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Activity Sponsor”). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described Activity or transportation to and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant, or otherwise.

I/We also acknowledge that the Activity Sponsor reserves the right to inspect any luggage, including but not limited to suitcases, duffle bags, backpacks, purses, etc., that the Participant may bring to the Activity. Such inspections shall be conducted solely for the purpose of maintaining the safety of all individuals who may be present for the Activity. When such inspections occur, they shall be done in full view of the Participant and all Participants are hereby warned that the Activity Sponsor may have an obligation to contact the proper legal and law enforcement authorities if items of questionable legality are found.

If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association or other agents designated by the CCUC Deacons Board.

I/We understand that all reasonable safety precautions will be taken at all times by CCUC staff and volunteers during the event and activities. In case of an emergency, I/we authorize any medical treatment by an accredited hospital and/or physician deemed necessary for the subject of the release.

I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk.

Acknowledgement *

I (parent or guardian of the participant) have read and agree with the CCUC Consent and Emergency Release form.

Lake Geneva Youth Camp and Conference Center
W2655 South Street
Lake Geneva, WI 53147
(262) 248-5500

LGF RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT, rev. 6-3-17

In consideration of participating in activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising from negligence Lake Geneva Foundation, Lake Geneva Youth Camp and Conference Point Center and its owners, directors, officers employees, agents, volunteers, participants, and all other persons or entities acting for them (hereinafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate, and also agree as follows:

1. I acknowledge that participating in any physical activity including, but not limited to, walking, running, hiking, basketball, volleyball, sand volleyball, soccer, dodgeball, human foosball, gaga ball, 9 square in the air, shuffle board, tether ball, playground equipment, floor hockey, broom ball, disc golf, horseshoes, fishing, tennis, softball, bocce ball, campfires, field games, any activity in the gym, game room, or any activity my group orchestrates while on property or any of the staffed elements including, but not limited to, archery, boat rides, banana boating, tubing (water and snow), waterskiing, wakeboarding, swimming, canoeing, paddle boating, kayaking, climbing wall, giant swing, mountain biking, paintball, teams course/challenge course, toboggan run, waterslide, zip line, zorb ball, and laser tag, involves known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage. Risks include, but are not limited to, broken bones, torn ligaments or other injuries as a result of falls or contact with other participants, insect bites (spiders, ticks, bed bugs, mosquitoes, etc.); death as a result of drowning or brain damage caused by near drowning in lakes or other bodies of water; medical conditions resulting from physical activity; and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.

2. I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

4. I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such condition.

5. In the event that I file a lawsuit, I agree to do so in the state where Releasees’ facility is located, and I further agree that the substantive law of that state shall apply.

6. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.

I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I agree to be bound by its terms.

In consideration of [pipe:0] [pipe:1] being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.

Acknowledgement *

We (the parent/guardian and participant) have read and agree with the LGF RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT.

Participant Name

Participant Age *

Camper Signature *

clear

Parent/Guardian Name *

Parent Guardian Signature *

clear

Date * +

Registration & Optional Fees

Camp Registration Fee *

By June 10 ($290)

June 11-July 1 ($299)

After July 1 ($310)

Does the camper attend CCUC? (also includes CCUC-S, CCUC-W, or CCUC-N)? *

Camper attends CCUC. (+$0)

Camper does not attend CCUC. (+$15)

Purchase Camp T-Shirt?

Yes (T-Shirt) (+$10)

No (T-Shirt) (+$0)

If purchasing a t-shirt, what size?

Optional Activities (Additional fees apply.)

Total Due

$0.00

Payment Information

Payment Options:

For students who are not local to the Chicagoland area, camp payments will be accepted at check-in at Lake Geneva Youth Camp on Monday, August 5, 2019. If you are local to the Chicagoland area, please submit you payment in advance according to the following:

BY CASH

If paying by cash, please visit the CCUC main office in the Impact Center (2nd Floor) during regular business hours and submit payment to the office staff on duty. Do not leave any cash unattended in any mailbox. Alternatively, you may visit Kingdom Seekers on any Friday night during the summer and submit your payment to a counselor directly. DO NOT SEND CASH IN THE MAIL!

BY CHECK

1. Make check payable to Chinese Christian Union Church and on the memo line, please write, "Student Name - Teen Camp".

2. Mail/deliver check to:

Chinese Christian Union Church

Attn: Teen Camp 2019

2301 S. Wentworth Ave.

Chicago, IL 60616