2024 Winterfest Student Application & Medical Release

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Church Name *

Church Phone Number *

Winterfest Group Leader/Student Pastor *

Winterfest Group Leader/Student Pastor Email *

First Name *

Last Name *

Male or Female *

Shirt size *

Age *

Grade *

Rooming Buddy?

Street Address *

City *

State *

Zip Code *

Mailing Address if different from above

Student Phone Number

Student Email Address

Student Insurance Company *

Student Insurance Policy Number *

Insurance Carrier Phone Number *

Parent/Guardian First & Last Name Please Specify Guardian/Mother/Father/Grand Parent etc. *

Parent/Guardian Phone Number *

Parent/Guardian Email Address *

Emergency Contact Person-Other than Parents/Guardians Listed Above *

Emergency Contact Cell Phone Number *

Physician Name *

Phone Number *

List allergies: *

Brief Health History: Athsma/Stomach or digestion/Epilepsy or seizures/Heart/Diebeties/Physical or Mental health concerns *

Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

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Date of last Tetanus shot: *

Glasses Required? *

Please list acceptable over the counter medications Adult Chaperones or medical personnel may administer, if necessary, without parent consent: Examples Tylenol, Mortin, Imodium, Peptobismal, Benadryl, etc. *

Signature of parent or guardian required below:
By signing I/We agree the student applicant has my permission to attend and be transported to and from all youth group activities sponsored by the Church/RMRCOG (Rocky Mountain Region Church of God) for the 2024 calendar year.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church/RMRCOG and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church/RMRCOG. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church/RMRCOG, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church/RMRCOG, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

I understand that my child will be the responsibility of and supervised by the adult leader who brings them to RMRCOG Winterfest 2024. I will not hold the Rocky Mountain Region Church of God Youth and Discipleship Department liable for accident or injury. I understand that the Rocky Mountain Region Church of God insurance is secondary to the participants insurance coverage.
I understand that refunds will only be given if the event is cancelled due to inclimate weather or acts of God.

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All Student Applicants must read and sign below:

I, the student, have read the rules of conduct, and the health and and safety limitations previously stated, I agree to abide by the personal limitations previously stated as well as the code of conduct while participating in all activities.

Activities may include, but are not limited to: cookouts, boating, swimming, basketball, roller skating, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, skiing, snowboarding, sledding, hiking, biking, horseback riding, service projects, mission trips, scavenger hunts, concerts, Bible studies, miniature golf, hayrides, hide & go seek, water balloon fights, capture the flag, bowling. (Transportation to/from activities may be included as part of that activity).

Note: If you desire to limit your child’s participation in any event (including transportation), please submit your wishes in writing to the church youth pastor prior to that event.

Please READ before signing!
I recognize that I am responsible for my behavior. I am dedicating myself to the lofty goal of preparing myself for an intense, life-changing, encounter with God. I will conduct myself in a respectful, mature, and courteous manner. I will adhere to all rules and policies and I will honor those who are over me in the Lord. I will do everything in my power to ensure that Winterfest 2024 is a spiritual success.

Signature:

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