Checklist for LVR Forms
Please fill out the enclosed forms for each camper attending LVR from your family.
Make sure you fill in ALL blanks and highlighted areas!
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Liability Consent Form
Medical and Dental Care Consent and Media Release Form
LVR Permission and Endorsement Form
LVR Health History Form
Team Initiatives Program Waiver
Lutheran Valley Retreat Trail Rides & Riding Program
Kansas District Camp Covenant
A Doctor signed Physical from the past 16 months
ALL FORMS HAVE TO BE TO THE LVR REGISTAR BY MARCH 31ST. PLEASE MAKE SURE YOU GET ALL YOUR
FORMS TO YOUR CHURCH’S COORDINATOR BY THEIR DUE DATE SO THEY CAN PASS THEM ALONG.
PHYSICALS ARE DUE ON MARCH 31ST AS WELL. YOU CAN USE LAST YEAR’S PHYSICAL FOR THIS IF IT WAS
WITHIN 16 MONTHS OF THIS YEAR’S CAMP.
ANY PARTICIPANT WHO DOES NOT TURN IN ALL OF THEIR FORMS AND HAVE THEM COMPLETED BY MARCH
31ST WILL RECEIVE A $25 PENALTY.
THE LUTHERAN CHURCH – MISSOURI SYNOD
KANSAS DISTRICT – YOUTH MINISTRY
LIABILITY RELEASE FORM
Name of Participant: ____________________________________________________________________
I understand that the Kansas District of the Lutheran Church Missouri Synod for which this medical Consent and
Liability and Activity Release Form is being given is described as follows:
All calendared and registered events for the Kansas District of the Lutheran Church Missouri Synod for youth and
adult leaders for calendar year 2015. The events include, but are not limited to, Kansas District Youth Gathering
(DYG), Junior High Rallies, Lutheran Valley Retreat Camp (LVR), Lutheran Youth Fellowship (LYF), Council of Lutheran
Youth Fellowship Representatives (CLYFR), Teen Leadership Retreat (TLR), National Youth Gathering (NYG), and Youth
Ministry Academy (YMA), these events may include, but are not limited to, mass plenary events, smaller group
interest center workshops, service projects, fellowship and experiential learning activities.
I hereby consent to participation of myself (or of my child) in the above-described Kansas District of the Lutheran
Church Missouri Synod events. I have read the informational materials regarding the planned activities. I am aware
that in addition to activities such as Bible study, Worship, sight-seeing, using public transportation, and meal
functions, the participant also may choose to participate in various recreational sports activities or service projects
that may involve additional risks, such as: jumping, running or other physical movements during sports activities; or
using tools or ladders or other equipment while taking part in the community service projects.
I understand that I have the duty to provide primary accident and medical insurance for myself (or for my child) and I
declare that I am (or my child is) covered by primary accident and medical insurance.
I RELEASE AND FOREVER DISCHARE THE KANSAS DISTRICT OF THE LUTHERAN CHURCH – MISSOURI SYNOD, IT
AGENCIES, AND ____________________________________ (NAME OF HOME CONGREGATION), THEIR AGENTS AND
SERVANTS, SUCCESSORS AND ASSIGNS, DIRECTORS, TRUSTEES, OFFICERS, EMPLOYEES, AND OTHER
REPRESENTATIVES FROM ANY AND ALL DAMAGES AND CAUSES OF ACTION EITHER AT LAW OR IN EQUITY THAT I MAY
HAVE AS A RESULT OF MY [OR MY CHILD’S] PARTICIPATION IN, ATTENDANCE AT, AND TRAVEL TO AND FROM THE
EVENTS. FURTHERMORE, I DO HERBY EXPRESSLY STIPULATE, AND AGREE TO INDEMNIFY AND HOLD FOREVER
HARMLESS THE KANSAS DISTRRICT OF THE LUTHERAN CHURCH – MISSOURI SYNOD, ITS AGENCIES, AND
________________________________________ (NAME OF HOME CONGREGATION), ITS AGENTS, AND SERVANTS,
SUCCESSORS AND ASSIGNS, DIRECTORS, TRUSTEES, OFFICERS EMPLOYEES, AND OTHER REPRESENTATIVES AGAINST
LOSS FROM ANY AND ALL PRESENT OR FUTURE CLAIMS, DEMANDS OR ACTIONS IN LAW OR IN EQUITY THAT MAY
HEREAFTER BE MADE OR BROUGHT BY ME OR MY CHILD, BY ANYONE ON BEHALF OF ME OR MY CHILD, OR BY
ANYONE ELSE ON THEIR OWN BEHALF FOR DAMAGES OR ANY OTHER LEGAL OR EQUITABLE REMEDY ON ACCOUNT
OF ANY INJURY, ILLNESS, PHYSICAL CONDITION, INCONVENIENCE OR LOSS SUSTAINED BY ME OR MY CHILD DURING
THE GATHERING OR TRAVEL TO AND FROM THE SAME.
I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the
same as my own free act and deed.
FOR PARTICIPANTS UNDER AGE 21:
___________________________________ __________ _____________________________________
Parent/Guardian of Participant
Date
Adult, Non Relative Witness to
Parent/Guardian Signature
THE LUTHERAN CHURCH – MISSOURI SYNOD
KANSAS DISTRICT – YOUTH MINISTRY
AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE
This form must be completed and signed by parent/guardian of participants under 21.
A parent/guardian signature is needed for participants to take part in any activities.
(I) (We), the undersigned parent(s) and/or natural guardians(s) of ___________________________________
(Dependant’s Name), a minor, do hereby authorize my child’s congregational Family Group Adult Leader, (and/or any
other adult appointed or designated by him/her) to
(i) consent to medical, surgical and dental care for such minor child,
(ii) consent to any diagnostic tests, medical, surgical or dental procedure or treatment as may be considered
therapeutically necessary by the physician, surgeon, dentist or other health care personnel providing care for
such minor child, and
(iii) on (my) (our) behalf, to
(a)employ physicians, surgeons, dentists, nurses, and other care personnel as may be deemed
necessary for such minor child,
(b) admit such minor child to any hospital, clinic, emergency room, laboratory or other health care or
diagnostic facility for examination, treatment, surgery or care, and
(c) sign all necessary consents and authorizations. It is understood that this authorization is given in
advance of the occurrence of any condition or situation which would necessitate any such medical,
surgical, or dental care being required but is given to provide authority to obtain such care if it should
be required.
I fully understand the consequences of the foregoing statements and sign the AUTHORIZATION TO CONSENT TO
MEDICAL AND DENTAL CARE knowingly, freely and willingly.
This authorization shall continue for such time my child is participating in the Kansas District LCMS events and during
travel to and from the Kansas District LCMS events.
________________________________
__________ _____________________________ _________
Parent/Legal Guardian
Date
Parent/Legal Guardian
Date
KS District LC-MS YOUTH MEDIA RELEASE CONSENT FORM
Permission for Publishing of Youth Likeness in Pictures and Video
We understand that my daughter or son’s likeness or picture may be selected by a staff member of the LC-MS Kansas
District or representative from the District Youth Ministry Team, to be used to record, promote, celebrate and
publicize our church ministry in many different venues including, but not limited to, our KS District website, slide
shows, congregational publications/registrations, social media sites (including Facebook, Twitter), etc. NO LAST
NAME, HOME ADDRESS OR PHONE NUMBERS WILL APPEAR WITH THE LIKENESS/PICTURES.
We hereby consent and grant permission to the Kansas District or the District Youth Ministry Team to publish, post
and use likenesses, pictures and videos described above and we hereby release the KS District and its agents
representatives and employees from all claims, demands and liabilities of any nature whatsoever in connection with
the above.
Date: _______________________
Youth/Minor Name (printed): ________________________________________________________________
Other Youth in Family: ________________________________________________________________
Parent’s/Guardian’s Name (printed): ___________________________________________________________
Parent’s/Guardian’s Signature: _______________________________________________________________
LVR PERMISSION AND ENDORSEMENT FORM
Circle Date of Camp Session: June 14-19, 2015 or July 19-24, 2015
Name _______________________________________
Birth date ___________________
Circle M/F
Address _____________________________________
City/State/Zip ________________________________
Parent Name __________________________________
Home Phone Number _________________________
Place of Employment ___________________________
Work Phone _________________________________
E-Mail _______________________________________
Cell Phone __________________________________
Parent Name __________________________________
Home Phone Number _________________________
Place of Employment ___________________________
Work Phone _________________________________
E-Mail _______________________________________
Cell Phone __________________________________
Emergency Contact Name _______________________
Other than Parent
Emergency Contact Address ______________________
Relationship to Camper _______________________
Family Medical Insurance Company ______________
Insurance Phone ____________________________
Insurance Address______________________________
Insurance City/State/Zip______________________
Emergency Contact Phone _____________________
Parent Permission & Endorsement
This health history is correct so far as I know & the child herein described has permission to engage in all prescribed activities
including, without limitation, climbing/rappelling, equine, low and high ropes courses, rafting, and walking or riding in camp
vehicles, except _____________________________________________________________________.
I understand that many of these activities are limited to 11 year and older youth. I hereby assume the risk of all injuries to the
person herein described & I release and discharge Lutheran Valley Retreat, its agents and employees from any and all liability
that results from injury to the person herein described. Insurance protection is my responsibility.
I give permission for the camp to administer medications as it deems necessary to this child, including medications sent with my
child or nonprescription medications available at camp. In the case of an emergency, I know every effort will be made to contact
me. In the event I cannot be reached, I hereby give my permission for the medic selected by the camp director to hospitalize
and secure proper treatment for my child.
I assume financial responsibility for actions that may cause damage to property.
If the staff deems it necessary for my child to be removed from camp, due to disciplinary or other problems I will respond by
promptly picking up my child from camp.
Signature of Parent/Guardian _____________________________
Date______________________
Please copy front and back of participant’s/cardholder’s insurance card in the space below:
Medical Card Copy Front
Medical Card Copy Back
LVR HEALTH HISTORY FORM
Circle Date of Camp Session: June 14-19, 2015 or July 19-24, 2015
Height: ________________
Camper Name__________________________
Weight:_________________
Current Medication: Please note, all prescription MUST be prescribed to this individual, within expiration date, and in their original packaging
Name of Medication
Reason
Dose/Schedule
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Health History Conditions
Health History Conditions
Anxiety/Depression
No / Current / Past
Frequent Colds
No / Current / Past
Epilepsy
No / Current / Past
Stomach or Intestinal Trouble
No / Current / Past
Ear/Nose/Throat Trouble
No / Current / Past
Diabetes
No / Current / Past
Eating Disorders
No / Current / Past
Frequent Ear Infections
No / Current / Past
Recurrent Headaches
No / Current / Past
Dizzy Spells/Fainting
No / Current / Past
Asthma
No / Current / Past
ADD or ADHD
No / Current / Past
Disease or injury to Joints or back
No / Current / Past
Bed Wetting
No / Current / Past
Heart Disease or Problems
No / Current / Past
Home Sickness
No / Current / Past
High Blood Pressure
No / Current / Past
Allergies
Describe
Reaction
Food
Yes / No ______________________________________________________________________________________________________
Medication
Yes / No ______________________________________________________________________________________________________
Environment (insect/animal/etc Yes / No ___________________________________________________________________________________________
Other
Yes / No ______________________________________________________________________________________________________
Dietary Needs
Limitations
Vegetarian
Yes / No ______________________________________________________________________________________________________
Gluten
Yes / No ______________________________________________________________________________________________________
Lactose
Yes / No ______________________________________________________________________________________________________
Immunizations (Fill out OR attach copy of immunizations chart)
Vaccination
Most Recent
Date
Vaccination
Most Recent
Date
Date of last Tetanus ______________________________
Vaccination
Most Recent Date
Vaccination
Most Recent
Date
Vaccination
Measles, Mumps,
Rubella (MMR)
Hepatitis A
HIB
Chicken Pox
(or had the
disease)
Influenza
Diphtheria/Tetanus
(DPT)
Hepatitis B
Polio
Other
Other
Most Recent Date
The camper is under the care of a physician for the following condition(s):__________________________________________________
________________________________________________________________________________________________________________
Other health, behavioral, social, or any other concerns to be aware of: ______________________________________________________
________________________________________________________________________________________________________________
Official Use only (camp staff only to be determined on site): The camper appears to be healthy and free of contagious disease and
capable of active participation for all camp activities. Circle one Yes No
___________________________________ __________ _____________________________________
Parent/Guardian of Participant
Date
Adult, Non Relative Witness to
Parent/Guardian Signature
LUTHERAN VALLY RETREAT (LVR)
TEAM INITIATIVES PROGRAM (T.I.P.)
PARTICIPANT RISK INFORMATION AND WAIVER
Youth’s Name __________________________________
Church
__________________________________
City
__________________________________
Please do not participate in this program if you believe it to be PERFECTLY safe. IT IS NOT, NOTHING IS! While your facilitators are skilled
and experienced, they are unable to guarantee total protection from all risks. You MUST pay close attention to and follow safety guidelines,
take responsibility for avoiding or minimizing risks, and develop a questioning attitude.
This program takes place outdoors. T.I.P. will involve activities outside. It is highly likely that you may get scraped or cut during your activity.
By paying close attention to the facilitators’ safety instructions throughout your experience you should be able to avoid any major injuries.
Outdoor settings present some inherent danger which may result in accidents. You should be aware of what you are committing yourself to
in this program. If in doubt, please ASK! LVR is 45 minutes from professional medical assistance and in 15 minutes Flight For Life can arrive
from Colorado Springs.
With each activity, there are many associated dangers (hazards). These dangers may include, but are not limited to, sharp rocks,
temperature extremes, adverse weather, lightening, equipment malfunctions and human misjudgment.
Certain safety procedures are taken to provide some protection against risks. These procedures may include, but are not limited to: using
safety equipment such as ropes and helmets, teaching of spotting techniques, providing opportunity for participants to make known medical
information (recent operations, pregnancy, weak/damaged lower backs, etc.) allowing participants to ultimately have the choice in their
challenge, facilitator spots, ability of group to decide to modify how members participate (within the metaphor boundaries) in an element
and/or abort an attempt.
Nonetheless, ACCIDENTS ARE ALWAYS POSSIBLE! Participants must realize that potential accidents may include, but may not be limited to
cuts, bruises, scrapes, strained muscles, broken bones, back injuries, and death. Participants must also do everything possible to help reduce
the potential for accidents. Accidents occur when human and environmental dangers combine at the same time. Any participant in a T.I.P.
program such as this has the fundamental responsibility to act in a safe and alert manner to prevent the combination of dangers and thus
avoid accidents.
I understand that the Team Initiatives Program sponsored by Lutheran Valley Retreat, Inc. is:
Name of Event: 2015 Kansas District Senior High Summer Camp
Date of Event: June 14-19, 2015
To Include:
√ Low Element Challenges
or
July 19-24, 2015 (Please circle the camp you are attending)
√ High Element Challenges
√ Climbing and Repelling on Natural Rocks
I hereby consent to participation of me or my child in the above-described LVR-T.I.P. program. I have read the above information and
understand the risks involved in the planned activities.
I understand that I have a duty to provide primary accident and medical insurance for myself (or for my child) and I declare that I am (or my
child) covered by accident and medical insurance.
I RELEASE AND FOREVER DISCHARGE LUTHERAN VALLEY RETREAT (LVR) AND THE LUTHERAN CHURCH-MISSOURI SYNOD (SYNOD), THEIR AGENTS AND
SERVANTS, SUCCESSORS AND ASSIGNS, DIRECTORS, TRUSTEES, OFFICERS EMPLOYEES AND OTHER REPRESENTATIVES FROM ANY AND ALL DAMAGES AND
CAUSES OF ACTION EITHER AT LAW OR IN EQUITY THAT I MAY HAVE AS RESULT OF MY (OR MY CHILD’S) PARTICIPATION IN, ATTENDANCE AT, AND TRAVEL
TO AND FROM THE TEAM INITIATIVES PROGRAM. FURTHERMORE, I DO HEREBY EXPRESSLY STIPULATE, AND AGREE TO INDEMNIFY AND FOREVER HOLD
HARMLESS LVR AND SYNOD, ITS AGENTS AND SERVANTS, SUCCESSORS AND ASSIGNS, DIRECTORS, TRUSTEES, OFFICERS, EMPLOYEES AND OTHER
REPRESENTATIVES AGAINST LOSS FROM ANY AND ALL PRESENT OR FUTURE CLAIMS, DEMANDS OR ACTIONS IN LAW OR IN EQUITY THAT MAY HEREAFTER BE
MADE OR BROUGHT BY ME OR MY CHILD, BY ANYONE ON BEHALF OF ME OR MY CHILD, OR BY ANYONE ELSE ON THEIR OWN BEHALF FOR DAMAGES OR
OTHER LEGAL OR EQUITABLE REMEDY ON ACCOUNT OF ANY INJURY, ILLNESS, PHYSICAL CONDITION, INCONVENIENCE OR LOSS SUSTAINED BY ME OR MY
CHILD DURING THE TEAM INITIATIVES PROGRAM OR TO AND FROM THE SAME.
I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the same as my own free
act and deed.
SIGNATURE OF PARTICIPANT (IF 18 & OLDER) OR PARENTING/GUARDIAN OF CHILD PARTICIPANT (IF UNDER 18)
______________________________________
_________
______________________________________
Parent/Guardian Signature
Date
Adult, NonRelative Witness to
Parent/Guardian Signature
Lutheran Valley Retreat Trail Rides & Riding Program
a program of Lutheran Valley Retreat, Inc.
RELEASE AND INDEMNITY AGREEMENT - ALL ADULT HORSEBACK RIDERS, 18 OR OLDER,
OR PARENTS OR GUARDIANS OF ANY PERSON UNDER THE AGE OF 18, MUST READ THE FOLLOWING CAREFULLY:
I have carefully read and understand this Release, have had the opportunity to ask questions about
this Release and all such questions have been fully answered. With full knowledge of its contents,
I hereby sign this Release voluntarily.
Name of Camper________________________________________________________Age____________
(Please Print) Last, First, MI
(As of Date of Arrival at LVR)
Signature of Camper_____________________________________________________Date___________
Signature of Parent______________________________________________________Date___________
(Signature of parent required if camper is under 18 years old)
Section A. Protective Attire.
+ I am hereby advised to wear a well-fitted helmet, hard hat, or similar protective head gear, fastened securely under the chin, while working around or
riding horses, to prevent injuries.
+ I am hereby advised to always wear hard-soled, fully enclosed shoes or boots and socks to protect feet, and long pants to protect legs while working
around or riding horses.
Section B. The Nature and Physical Character of the Horse.
1. I am advised that while domesticated, well-trained horses are usually obedient, docile, and often affectionate, it is important to understand that their
survival instincts are what has allowed the horse to survive from prehistoric times to the present day.
2. I am advised that horses are unpredictable by nature, with minds of their own, as are all animals both domestic and wild. The horse is often somewhat
high strung or nervous by nature. Horses are physically powerful and extremely heavy, weighing from 600 to 1,300 pounds on the average. These
characteristics deserve a human being’s utmost respect.
3. I am advised that when a horse is frightened, angry, under stress, or feels threatened, it is his instinct to jump forward or sideways, to run away from
perceived danger at a trot or gallop at speeds up to 35 miles per hour.
4. I am advised that if a horse is frightened or feels threatened from behind, it may kick straight back, sideways in either direction, or even forward with
either of its hind legs with tremendous force.
5. I am advised that if a horse is frightened or feels threatened from above or to its back, it may hunch its back and buck in away that could throw a rider to
the ground with tremendous force.
6. I am advised that if a horse is frightened or feels threatened from the front, it may naturally react by rearing up with its front legs, strike with one or both
front legs, bite with its teeth, throw its head up or from side-to-side, or run directly over whatever it fears in front of it.
7. I am advised that a human must always approach a horse calmly, quietly, and cautiously, preferably from near its shoulder or lower neck, talking
soothingly to it. I am advised that loud and/or sudden or unexpected movements, dropping of objects near a horse, approaching vehicles or animals or
people, ill-fitting equipment or physical pain can provoke a domesticated horse to react according to his natural protective instincts.
8. I am advised that the first signs of danger or fear in a horse are the sudden tensing of the muscles of the body, possibly laying its ears flat back against its
head, or quickly tossing or raising its head, or sudden snorting through the nostrils accompanying at least one other warning sign.
9. I am advised that a horse can see independently with each eye, actually looking in one direction with one eye and another direction with the other eye, or
it can focus both eyes on one object somewhere in front of it; that usually the direction the ear is pointing will tell an observer where the eye on the same
side is looking, and consequently, where the horse’s attention is focused.
10. I am advised that a horse has two blind areas around it which it cannot see. It cannot see directly behind it, nor what it is eating. This is the reason it is
best to approach a horse close to the shoulder, and never to surprise a horse from the rear or to reach first for the horse’s mouth.
11. I am advised that while a horse is very sure-footed by nature, it may accidentally step on an object such as a human foot when it is balancing itself or
turning around; also that if a horse is ridden or worked on unstable ground or slippery grass or footing, it could fall, injuring a rider or handler.
Section C. Release
WARNING: Under Colorado Law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the
inherent risks of equine activities, pursuant to section 13-21-120, Colorado Revised Statutes.
Upon acceptance of horse and equipment, I acknowledge that the use, handling, and riding of a horse involves a risk of physical injury to any individual
undertaking such activities; and that a horse, irrespective of its training and usual past behavior and characteristics, may act or react unpredictably at times,
based upon instinct or fright, which, likewise, is an inherent risk assumed by a horseback rider.
The abovesigned expressly assumes such risk and waives any claim whatsoever, including, but not limited to, claims for negligence, breach of any warranties,
or breach of contract he/she might state against Lutheran Valley Retreat, Inc., its Officers, employees, agents, or representatives, (Indemnities) from any and
all costs, medical expenses, attorneys’ fees, court costs, jury verdicts, settlement amounts, or other monetary damages incurred by or assessed against
Indemnities and arising in any way from my participation or my child’s participation in any horseback riding activity, camp or clinic involving the use,
handling, or riding of a horse. I further agree to hold harmless and indemnify the Indemnities against any claims, demands, or lawsuits brought by anyone,
including my child, for any negligence of the Indemnities, losses, damages, or injuries arising from my participation or my child’s participation in any
horseback riding activity, camp, or clinic involving the use, handling, or riding of a horse.
Kansas District Camp Covenant
Lutheran Valley Retreat
We, the undersigned, have read and agree to uphold this covenant.
Please indicate the camp you are attending: _____ June 14-19, 2015
or
_____ July 19-24, 2015
Name of Camper________________________________________
Signature of Camper_____________________________________
Signature of Parent______________________________________
Date___________
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In all we do at Camp, we keep this in mind: God is present; we represent God and the Church;
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For our own safety, we will not go out alone.
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We understand that illegal activity, as well as the use or possession of any alcoholic beverages or drugs, by
camp participants (youth and adults) is prohibited both on and off the camp property during the camp
week;
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For the safety of all campers, we understand that periodic searches of luggage and personal belongings
may occur by staff members;
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We will report any illness or personal emergency to our group leader. If we cannot find our group leader,
or need additional help, we will go to the Camp staff or the camp office for assistance;
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We understand that if we break or damage anything at Camp, we are responsible for working with the
camp and fully paying for the repair;
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We agree to be quiet and inside our own cabins during the listed curfew time (unless we are with an Adult
Leader and quiet);
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We agree to adhere to a dress code that is modest and appropriate. We will abide by the dress code as
stated and found on the Kansas District website (see LVR Summer Camp link);
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We agree not to do anything that would jeopardize the enjoyment or safety of the other participants;
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We agree to abide by the guidelines stated above and to help one another keep this covenant;

We will abide by the rules of LVR as they are explained when we arrive.

We will agree to use cell phones ONLY during specific travel times – these times will be announced on the
bus. Any movie/video watching will NOT be permitted on any individual electronic device at any time
during the trip (cell phones do not work at camp);
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If we choose not to follow the covenant, we understand and accept the consequences decided upon by
our Adult Leaders and/or Camp Staff.
We understand and agree that if the need arises for a student to be sent home, parents are responsible for
coming to camp to take him/her home and bear all expenses.
SAMPLE
PHYSICAL EXAMINATION
PRE-PARTICIPATION
PHYSICAL
EVALUATION
Name: ______________________________________________________ Date of Birth: ________________
Height: ___________
Weight: ___________ Pulse: ___________ Blood Pressure: ___________________
Vision
R 20/____
L 20/____
Corrected: Y N
Pupils: Equal Unequal
Date of recent immunizations: Td _______________ Tdap _____________ Hep B _________________
Varicella __________ HPV ______________ Meningococcal __________
Normal
Abnormal Findings
Initials*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Genitalia/Hernia
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*Station-based Examination only
CLEARANCE
Cleared for all activities
Not cleared for: _________________________________________________________________________________
Reason: ________________________________________________________________________________________
Recommendations: ______________________________________________________________________________
______________________________________________________________________________________________
I HEARBY CERTIFY THAT I AM QUALIFIED BY TRAINING AND EXPERIENCE TO PROPERLY PERFORM
THE EXAMINATION AND MAKE THE EVALUATION REFLECTED ON THIS FORM
Name of Physician (print/type)________________________________________________________Date _________________
Address ________________________________________________________________Phone (______) __________________
Signature of physician ________________________________________________________MD, DO, DC or RPA (Please Circle)