Harmony Church Youth 
Camp Fortune Aerial Experience
Sat. August 23rd, 2014
300 chemin Dunlop Chelsea, QC

Consent and Release Form
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On August 23rd, 2013, the Harmony Church Youth group is going to Camp Fortune Aerial Experience (http://campfortune.com/summer/explorer/) at 300 chemin Dunlop Chelsea, QC, J9B 2N3; 819-827-5517.  Cost for ages 13-17 years is $29 + tax, adults $35 + tax.  Please call or text Daren at 613-445-3287 to arrange pickup at sometime between 8:30am & 9:00am.  Everyone should be home sometime around 4:00pm.

In the event that the participant requires special medication, x-rays, or treatment, the parents/guardian will be notified immediately. If the parents/guardian cannot be contacted the emergency contact will be called.  In the event that neither can be contacted, the adult representative of Harmony Community Church will work in co-operation with the doctor to make any medical decisions that are deemed necessary for the well-being of the participant.

The undersigned acknowledges and voluntarily assumes all risk in any way with participating in a Harmony Church Youth event.  The undersigned hereby waives for themselves, their heirs, executors, administrators and assigns, any recourse he or she may have against Harmony Community Church and its directors, officers, volunteers, organizers, employees, sponsors, successors, assigns and agents, and releases and discharges such persons from all claims, demands, damages, actions or causes of action whatsoever, and absolves such persons from all responsibility for any injuries that may arise in any way in connection with the Harmony Church Youth event.

We further hereby undertake to hold and save harmless and agree to indemnify all of the aforesaid from and and against any or all liability incurred by any or all of them arising as a result of or in any way connected with my participation in the Harmony Church Event.  

By submitting this registration form, we acknowledge having read, understood, and agreed to the above waiver, release and indemnity.  We consent to and warrant that the Participant is physically fit to participate in this event.

Signature of Participant:____________________________________________________________

Name of Participant:______________________________________Date:_____________________

Health Card #:________________________________________________ version#:____________

Medications/ allergies:_____________________________________________________________

Signature of Parent/Guardian if Participant is under 18:

______________________________________________________Date:______________________

Name of Parent/Guardian:_________________________________Phone#:____________________

Emergency Contact Name:_________________________________Phone#:___________________

Minimum reach requirement
Full courses (zone 1-5): 1.75 m

Minimum reach requirement is measured as the distance from the ground to the middle of your palm, with your arm fully extended upwards. See images above.