Godspeak Calvary Chapel Retreat Form Registration and Consent to Participate

Participant's Information:

If the participant is a minor:

I, the parent or Legal Guardian of the above named, give my consent to have my son/daughter participate with the leaders from Godspeak Calvary Chapel in the event on the dates of:

I, the undersigned, agree to the terms above:

Health History

To protect you, the following information is requested.

General (Please check all that apply)






To your knowledge, have you been exposed to any communicable diseases within the past 21 days?

Do you know of any health factor that makes it advisable for you to follow a limited program of physical activity?

Please give us the name and phone number of your regular physician:

- -

If participant is a minor:

The health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted by me and/or my physician. I hereby give permission to the physician selected by the Youth Director (or his leaders) to order X-rays, routine tests, and treatments for the health of my child and to order injection and/or anesthesia and/or surgery for my child in the event of an immediate emergency. This authorization is given pursuant to section 25.8 of the Civil Code of California. This authorization shall remain effective through the extent of the scheduled program by Godspeak Calvary Chapel, unless sooner revoked in writing and delivered to said agent. I further agree that Godspeak Calvary Chapel and all staff, board, and volunteers are hereby relieved of all liability in the event of an accident or injury to said Minor.

To be signed by the Parent/Legal Guardian

I, the undersigned, agree to the terms above:

To be signed by the Minor/Camper

I, the undersigned, agree to the terms above:

- -

If participant is 18 or older:

The health history is correct so far as I know. I hereby release all staff and volunteers at Godspeak Calvary Chapel of all liability regarding any bodily harm that may occur to me during the duration of this event. I give consent to any trained professionals to administer any assistance necessary in the event of any accident.

I, the undersigned, agree to the terms above:

Emergency Contact 1

- -

Emergency Contact 2

- -