YOUTH  RETREAT LIABILITY RELEASE FORM

***LIABILITY RELEASE FORM BELOW MUST BE COMPLETED & SIGNED FOR ALL PARTICIPANTS***

Name of Activity: ESCAPE Youth Retreat
Location: Camp Wyoming- Wyoming, IA
General Information: 651-334-2146
Date of Activity: February 17-19

The undersigned do hereby release, forever discharge and agree to hold harmless CrossRoads Church and their respective members from and against any and all liability, claims, demands, lawsuits and expenses of any kind arising from personal injury, sickness, death or property damage of any kind whatsoever which may be incurred or suffered by the undersigned and/or participant (if participant is under 18, 18 or older).

If participant is under 18 years of age, I, the parent or legal guardian of the participant, do hereby grant
permission for my child to participate fully in the Youth Retreat and all of its activities. In the event that I or my emergency contact can’t be reached, I hereby give permission to the representatives of CrossRoads Church to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery and I fully and completely assume all responsibility for all medical bills.

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or
otherwise, I assume all responsibility and transportation costs.

This form MUST be signed by ALL participants.

If participant is under 18, parent or legal guardian must sign.

Name____________________________________________    Age______     Gender: Male  or  Female

Address ___________________________________City ___________________State ______Zip ________

Phone : _____________________

Participant’s signature   ____________________________________________Date______________

Parent or Legal Guardian Signature_______________________________________Date______________

Please return to Val Gaff.

or

You can scan and email to office@crossroadspeosta.org