Oriental Mission Church Youth

Camp Date 07/26/2019 - 07/28/2019

Summer Retreat for Oriental Mission Church Youth Group


After you submit the waiver of liability you will receive a confirmation email with a printable copy for your records.

If you would rather download and print the form so it can be filled out and faxed or mailed click here.

In exchange for permission to participate in The Salvation Army - Pine Summit programs and activities (“Camp’’), I or my minor child named above (“Camper’’) agree to the following:

Consent to Attend Camp (Where Camper is a Minor)

I hereby give permission for minor Camper to attend and participate in Camp.

WAIVER of Liability

I understand that some of the activities at Camp involve risk of property damage and of personal injury, illness or even death of Camper, including but not limited to the risks arising from transportation-related activities, recreational activities, accidents in the outdoors and rustic facilities, adverse weather conditions, and injuries and illness as a result of food-borne illnesses and allergic reactions.

By signing this Consent and Waiver of Liability, I warrant that Camper is fully capable of safely participating in all Camp activities. I agree to assume all risks of Camper’s participation, whether such risks are known or unknown to me at this time and hereby waive any and all claims I or my Camper may have against Pine Summit, and their directors, officers, employees, volunteers, and agents, and other campers at the Camp, for property damage or personal injury, illness or death of Camper as a result of participation in Camp activities, whether on or off Camp grounds. I agree that this release includes the ordinary, special and inherent risks described above, and other risks that I may not foresee or be aware of at this time. This Waiver of Liability is given on behalf of myself, my minor child (if Camper), and the heirs, family, estate, administrators, executors, personal representatives and assignees.

I understand that by signing this Consent and Waiver of Liability, I give up my right and the Participant’s right to sue The Salvation Army. I agree that if any provision or part of any provision or the application of such is held invalid, illegal, or unenforceable, the validity of all other provisions in this Consent and Waiver of Liability shall remain unaffected.


Camp may provide minor emergency medical treatment at the request of the Group or Camper, provided that qualified staff is available. Otherwise, all medical emergencies will be referred to the nearest medical treatment facility.

Other Releases and Acknowledgements

I understand that, while Camper is participating in Camp activities, photographs, film, audio recordings and videotape of Camper may be taken for use in brochures, videos, releases to the press, and various Pine Summit publications and other work product. I do hereby irrevocably grant Pine Summit permission to record, display and/or reproduce Camper’s name (first name only), likeness and voice on audio and/or video tape, film or other media, to edit and otherwise modify such media at its discretion, to incorporate the media into any work product, and to use or authorize the use of such media or any portion thereof in any manner or media or by any means, methods or technologies now known or hereafter to be known.

Adherence to Policies and Guidelines

I ensure that Camper will adhere to the Camp policies and guidelines. If Camper fails to abide by established rules and/or standards of conduct, Camp staff reserves the right to send Camper home. If it becomes necessary to send Camper home, I hereby agree to provide transportation or to make travel arrangements for Camper and to assume the cost of these expenses.

Medical Insurance Information

Yes, the camper is under the age of 18 years of age
No, the camper is 18 year of age or older








Sinus Trouble/Hay Fever
Heart Trouble
The Camper doesn’t suffer from any of the conditions listed

Contact Information

Yes, I acknowledge that I have read this document and that all the information provided is accurate.