Timberline Release Form
Agreement to participate, Assumption of risk and release for Timberline Baptist Camp
15363 FM 1849, Lindale, TX 75771
Name of Participant *
Your answer
Participant Date of Birth *
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Age of Participant *
Your answer
Participant's Address (house, street, city, zip) *
Your answer
Phone Number *
Your answer
Person to be contacted in case of an emergency: (Name, relationship, phone number) *
Your answer
Person to be contacted in case of an emergency: (Name, relationship, phone number) *
Your answer
Family Physician (Name, phone number) *
Your answer
Insurance Company *
Your answer
Insurance ID # *
Your answer
Insurance Group # *
Your answer
Insured's Name *
Your answer
Insured's SSN
Your answer
Does participant have or has had any heart problems? *
Does participant frequently suffer from pains in their chest? *
Does participant often feel faint or have spells of severe dizziness? *
Has a doctor ever told participant that they have high blood pressure? *
Does participant have arthritis, joint or back problems that might be aggravated by exercise? *
Has participant had any operations or serious injuries? (If yes, please give dates, if No, type "no") *
Your answer
Does participant have any disabilities or chronic or recurring illness? *
Are there any activities to be limited or discouraged by physician's advice? *
Is participant allergic to any medications, insects or pollen? *
Does participant have epilepsy? *
Does participant have diabetes? *
Does participant have any prescribed meal plan or dietary restrictions? *
If you answered "yes" to any of the above questions, please explain here. *
Your answer
Last date of Tetanus/Diphtheria? *
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What medication/s is the participant currently taking? *
Your answer
What medical condition/s is the participant being treated for? *
Your answer
Please give a statement of the participants current health. (List all allergies please.) *
Your answer
The proposed Recreational Activities, including but not limited to: Challenge Course Activities, Paintball, or Horseback Riding, provided by Timberline require participation in physical exercises which are, by their nature, demanding. Many of the activities will challenge you and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical conditions which might create undue risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination. I am aware that during my participation in recreation at Timberline upon my request certain risks and danger may occur. These include, but are not limited to, the hazards of being in a wilderness area, the forces of nature, and other reasons concerning this special environment. I have and do hereby assume all risks and will hold staff, officers, and trustees harmless from any and all liability, actions, cause of action, debts, claims and demands of every kind and nature whatsoever which I now have or which may arise from or in connection with my participation in any activities arranged for me by Timberline and its staff. The terms hereof shall serve as a Release and Assumption of Risk for my heirs, executors, and administrators and for all members of my family. In case of accident or illness Timberline will attempt to provide first aid and arrange transportation to medical services, if needed. Timberline does have limited secondary insurance. Assumption Of Risk And Release Form must be completely filled out and signed by the participant and by parent or legal guardian (for children under 18). These forms must be given to Timberline staff upon arrival to Timberline. The health history above is correct, so far as I know, and I believe that my health is satisfactory to participate in all scheduled activities. *
I give my consent for my child to participate in all activities: *
This form gives Timberline permission to take my child's picture, individually or in a group and publish it for promotional purposes only. *
As the parent of guardian of the above mentioned participant, I authorize a nurse or physician or other authorized personnel to examine, treat, or administer medications for ant illness or injury to my child as deemed necessary. In the event of an emergency and if I cannot be reached my telephone, I authorize such persons to obtain medical care from a licensed, certified or authorized health care provider for my child as deemed necessary. I accept sole responsibility for the payment of care. I hereby release, indemnify and hold harmless Community Life Church and Timberline Baptist Camp, its agents and employees, from and against any and all claims, liabilities, or negligence of any such health care provider or of Community Life Church and Timberline Baptist Camp, its agents and employees. *
By typing my full name below, I am authorizing this electronic signature as my own. Please date as well. *
Your answer
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