Education Retreat Information

Education Retreat Information

Organization Name:   Retreat Title:

Participant Information

Date of Birth:   Student ID:   Grade/Program:

Parent / Guardian (if participant is minor)

Relationship:   Primary Phone:   Email:

Retreat Details

Location:

Start Date:   End Date:

Emergency Contact Information

Relationship:   Phone:   Alternate Phone:

Medical Information & Authorization

Health Insurance Provider:   Policy Number:

I authorize staff to administer over-the-counter medications (acetaminophen, ibuprofen, antacid, antihistamine) per label directions as needed.

I authorize the organization and its agents to obtain emergency medical treatment for the participant if required and to release relevant medical information to treating medical professionals as necessary. I agree to be responsible for all costs associated with emergency treatment not covered by insurance.

Activities & Transportation Consent

The participant will be permitted to participate in the following activities (check all that apply):

Hiking    Water-related activities    Low/high ropes course    Other:

I consent to the participant being transported by organization-owned vehicles, contracted carriers, or staff vehicles for retreat-related travel.

Media Release

I grant permission for photography, audio, and video recording of the participant during retreat activities and consent to the use of such media by the organization for educational and promotional purposes, subject to approval by the organization and consistent with applicable privacy protections.

Conduct, Liability & Acknowledgment

I acknowledge that participation in retreat activities carries inherent risks. I agree that the participant will follow all rules, instructions, and directives of staff and supervisors. I accept financial responsibility for any damage or loss caused by the participant's intentional misconduct. The organization retains authority to discipline or remove a participant for behavior that endangers self or others; if removal is necessary, I accept responsibility for arranging and paying for transportation home.

By signing below I certify that the information provided on this form is complete and accurate to the best of my knowledge. I authorize medical personnel to provide necessary treatment in my absence, and I release and hold harmless the organization, its employees, volunteers, and agents from liability for injury or loss arising from participation except to the extent caused by gross negligence or willful misconduct.

Fees, Cancellation & Special Instructions

Certification & Authorization

I hereby certify that I am authorized to provide the information and consents contained in this form. I agree that in the event of an emergency the organization may share necessary medical information with medical providers and will make reasonable efforts to notify the emergency contact listed. I understand that false statements or omissions may jeopardize the participant's health and may result in revocation of participation privileges.

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