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Texas Liability Release Form 3

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This liability release form is provided by Heart of Texas Baptist Camp and Conference Center to release its future liability during the camper's participation in any camp activity.

Texas Liability Release Form 3 Page 2
Texas Liability Release Form 3
Health Statement
Form
Heart of Texas Baptist Camp and Conference Center
8025 N FM 2125, Brownwood, TX 76801 (phone) 325-784-5821 (fax) 325-784-6293 [email protected]
The proposed activity provided by Heart of Texas Baptist Camp and Conference Center requires participation in physical exercises that
are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates.
Therefore, all participants must be free of medical or physical conditions, and heart related or other diseases, which might create undue risk
to themselves or any others that depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is
any doubt about your ability to safely participate in this exercise, you should have a physical examination and get a release signed by your
physician. Your instructor reserves the right to deny participation to anyone for any reason.
Name: _________________________________________________________ Date of Birth: _________________________
Address: _______________________________________________________ Gender: ______________________________
City/State/Zip: ___________________________________________________ Age: ________________________________
Work Phone: ____________________ Home Phone: ____________________ Cell Phone: ___________________________
Name of Physician: _______________________________________________ Physician Phone: ______________________
Date of last physical examination: ________________________________________________________________________
EMERGENCY CONTACT:
In case of emergency, notify
_______________________________ Relation: ________________
Home Address: ________________________________________ City/State/Zip: __________________________________
Work Phone: _____________________ Home Phone: ____________________ Cell Phone: __________________________
MEDICATIONS:
List all current medications taken, prescribed dosage, and the frequency of dosage. Attach a separate sheet if necessary.
According to Texas law, all medications, prescription & non-prescription, MUST be held & dispensed by the camp nurse. The only
exceptions are asthma inhalers or emergency meds that must be carried at all times, however they must be reported and listed on this form.
Current medication: 1) ___________________________ Prescribed Dosage: _______________Frequency: _____________
Current medication: 2) ___________________________ Prescribed Dosage: _______________Frequency: _____________
Current medication: 3) ___________________________ Prescribed Dosage: _______________Frequency: _____________
HEALTH HISTORY:
Check any and all conditions that apply and explain in detail. Attach a separate sheet if necessary.
Allergies (please specify any and all below), Diabetes, Arthritis/Joint Problems, Heart Problems,
High Blood Pressure, Asthma, Seizures, Hypertension, Bleeding Disorder, Thyroid, Kidney, Epilepsy,
Recent Operations/Injuries, Disability/Chronic Recurring Illness, Dietary Restrictions, Other: _________________
Please explain condition(s) in detail: _______________________________________________________________________
____________________________________________________________________________________________________
IMMUNIZATION RECORDS:
Texas state law requires this form to have a current & correct immunization record for anyone under
the age of 18 attending camp. Please check and fill in the exact dates for each of the following immunizations or attach a current shot record.
DPT/DT
Date:
__/__/__ Polio
Date:
__/__/__ MMR
Date:
__/__/__ TB
Date:
__/__/__ Other
Date:
__/__/__
(Only if applicable)
I have chosen to not have my child immunized:
(Parent/Guardian Signature)
_________________________
PERSONAL INSURANCE INFORMATION:
Please provide a photocopy of your insurance card. In case of emergency,
personal insurance would cover as primary and camp insurance would cover as secondary.
Insurance Carrier: __________________________ Policy #: __________________ Group #: ___________________
Suggestions or other health-related information: ________________________________________________________
General Health Statement: _________________________________________________________________________
REPRESENTATION AND EMERGENCY AUTHORIZATION:
I ___________________________ acknowledge the above information is correct to the best of my knowledge. And I believe my health is
satisfactory to participate in all Camp activities including, but not limited to, Challenge/Ropes Course (highs and lows), Paintball, Water
Crafts, Water Toys, Lake Inflatables, Slip-N-Slide, Swimming Pool, Bicycles, Basketball, Softball, Soccer, Volleyball or any and all other
recreational sports activities. Furthermore, I give permission to the Heart of Texas Baptist Camp and Conference Center’s management,
trained CPR/First-aid activity facilitators, medical staff, and/or the group director to provide medical treatment that may be deemed
necessary to insure the well-being of the named attendee/participant.
______________________________________________________ ______________________________
Signature of Attendee/Participant Date
_____________________________________________________________ __________________________________
Signature of Parent or Guardian (if Attendee/Participant is under 18) Date
Texas Liability Release Form 3
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