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Joshua Tree 2019
Please fill out this form and pay a $10 nonrefundable deposit (link provided on next page) to hold your student's spot for Joshua Tree. Friday, May 3 through Sunday, May 5. Total cost: $60 (plus food groups) 8th -12th grade
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's Grade in School (2018-2019) *
Camp T-Shirt Size *
Gender *
Parent/Guardian Name *
Your answer
Relationship to Student *
Your answer
Street Address *
Your answer
City, State, and Zip *
Your answer
Cell Phone Number *
Your answer
Parent/Guardian Email (Main form of communication will be done via email.) *
Your answer
Does Your Student Have Any Allergies? *
Your answer
Are there any medical issues we should be aware of? *
Your answer
Name of Insurance Provider *
Your answer
Parent/Guardian Waiver: I understand a student who does not abide by the rules of the Church of the Open Door may be dismissed from any and all events. Signature of Parent/Guardian on this form waives and releases C.O.D. and its workers/volunteers from liability due to injury or illness incurred at C.O.D. or traveling to and from the church. Participants are responsible for their own property. Church of the Open Door and its workers/volunteers will not be responsible for lost or stolen items. *
Required
Photo Release: I give the Church of the Open Door and its employees and agent the right to photograph my child and use the photo and/or other digital reproduction of him/her or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing including via the internet. *
Autorization to Consent to Treatment of Minor: (I) (We), the undersigned, parent(s)/guardian(s) of the aforementioned student, a minor, do hereby authorize Church of the Open Door and its leaders as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. 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 our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgement may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until the parent(s) have indicated otherwise in writing to said agent(s). I, the parent/guardian, shall indemnify, hold free and harmless, assume liability for, and defend Church of the Open Door, its agents, servants, employees, officers, and directors from any and all costs and expenses including but not limited to, attorneys' fees, reasonable investigative and discovery costs, court costs, and all other sums which Church of the Open Door, its agents, servants, employees, officers, and directors may pay or become obligated to pay on account of any, all and every demand for, claim or assertion of liability, or any claim or action founded thereon, arising or alleged to have arisen out of the aforementioned student, use of real personal property belonging to Church of the Open Door, its agents, servants, employees, officers and directors, or by any action or omission by the aforementioned student. *
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