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Medical Treatment Consent and Liability Release Form

It is my desire that my child/ward participate in the activities of Ventura Missionary Church, therefore:

I the undersigned guardian, do hereby authorize the adult sponsor of Ventura Missionary Church or any responsible adult person bearing this written authorization, into whose said care the below mentioned minor child has been entrusted, to obtain proper medical care from a licensed medical or dental doctor or facility.  The medical/dental care is to include, but not limited to, any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a licensed medical doctor or dentist.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of said adult person to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician or dentist in the exercise of his best judgment may deem advisable. This authorization shall include transportation to receive the medical or dental care.

It is understood that while participating in activities at Ventura Missionary Church, my child is to follow the guidelines set by the adults in charge. Should my child not cooperate with these guidelines, I agree to pick up him/her from the activity.

Financial Responsibility

In the event of injury to my child/ward I agree that I/we and my health care insurer shall be financially responsible for any medical treatment required by my child/ward as a result of any injury or illness suffered during his/her participation in any church-related activities.

Risk

I am aware that these activities may involve some hazards.  I have considered these risks, and I still wish my child/ward to participate. Furthermore, I agree not to bring legal action against Ventura Missionary Church, staff or sponsors as a result of any injuries suffered in the course of his/her participation.

Dispute

In the event a dispute arises between me and Ventura Missionary Church concerning injuries to my child/ward, then I agree that the dispute shall be resolved by a Christian arbitrator acceptable to both sides. The cost of the arbitrator is to be shared equally by the parties. All applicable statutes of limitation shall apply and arbitration must be requested within the appropriate period in order to preserve a right to recovery.

Term of Agreement

This authorization will remain in effect from from July 1, 2022 - June 30, 2023 while the minor above is involved or participating in any program or activity authorized by Ventura Missionary Church, unless revoked by the undersigned in writing and delivered to the agent of Ventura Missionary Church.

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to recieve weekly email updates from our Student Ministry department
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medical Information

Doctor's Name *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *
Parental Statements and Permission for Camp
I give permission for the use of the following by Big Bear Lake Christian Conference Center (BBLCCC) for promotional purposes: (a) pictures taken while at camp; (b) quotations from evaluations/letters relating to camp experience; (c) video tape or audio recordings

I understand that if the above mentioned camper(s) participates in any illegal activity while at camp such as drinking alcohol, stealing or taking illegal drugs, they may be sent home immediately at the parent's expense

The health history provided on this form is correct and the camper(s) here in described as my permission to engage in all camp activities unless noted above.

I realize that individuals at camp can injure themselves without fault on the part of BBLCCC and release BBLCCC from responsibility for injury to this camper/these campers

I understand that Big Bear Lake Christian Conference center is located in a remote mountain region and that emergency care, even by ambulance can take up to 15 minutes. The camper(s) named above has no current condition that would warrant closer emergency medical care

I give permission to the medical personnel selected by the Health Supervisor, as well as the distributor of medications, to provide emergency medical treatment for the above-named camper(s) as deemed necessary. This may include transportation to a medical facility. In the event of an emergency in which I cannot be reached, I hereby give my permission to the physician selected by camp medical personnel to secure and administer treatment, including hospitalization fro the above named camper.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Medical Information
Does the camper have a chronic or recurring illness or medical condition? (i.e. seizures, ADD, depression etc.) please give details in area given for explanation*
No
Yes
Has the camper been hospitalized recently? please give details in area given for explanation*
No
Yes
Does the camper have any allergies to medications? please give details of medication and reaction in area given for explanation*
No
Yes
Does the camper have up to date vaccinations (as required by school district)?*
No
Yes

Date of last tetanus shot *
Does the camper have any allergies? Please list all items allergic to and symptom(s) of allergy attack in area given for explanation*
No
Yes
Does the camper have asthma? If yes, please give details in area given for explanation*
No
Yes
Does the camper have heart disease?*
No
Yes
Does the camper have any physical/mental/psychological condition requiring special treatment? (If yes, please explain in explanation section)*
No
Yes
Does the camper have insulin dependent diabetes?*
No
Yes
Does the camper have activity restrictions/limitations?*
No
Yes
Does the camper have Hepatitis B vaccine series?*
No
Yes
Does the camper have any dietary restrictions? (the camp is not equipped to provide special diets)*
No
Yes

Please fully explain all yes answers here

Please list all medications taken by camper (including dosage, frequency and type of illness being treated)
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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