VICTORY RANCH
Participation Agreement & Medical Release
(for adults, age 18+)

     I, the undersigned, as an attending participant with South Shores Church on November 15-17, 2024 at Victory Ranch, do understand and agree that attendance and participation in activities presents known and inherent risks to the participant and may result in injury, illness, exposure to infectious/communicable disease, death, and/or other damages.
     I, the undersigned, authorize Victory Ranch, its employees, volunteers, and/or agents to render or obtain such emergency medical care or treatment as may be necessary should any injury, illness, harm, or accident occur while participating in the above named camp program and its activities. I understand and accept that I am responsible for any medical obligations and shall be liable and agree to pay all costs and expense incurred in connection with such medical services rendered, including all transportation costs. My signature below serves to indicate my willingness to take full financial responsibility for any and all medical service rendered. My signature also serves to indicate my willingness for the Health Insurance Company named below to be billed for any and all medical fees and services required.
     I, the undersigned, do hereby release and agree to hold harmless Victory Ranch and its directors, board, agents, employees, volunteers, and representatives from any and all liabilities or claims for personal or emotional injury, illness, exposure to infectious/communicable diseases, and/or death, as well as property damage and/or expenses of any nature whatsoever which may be incurred by me that occur within the effective dates stated above and/or while participating in the above named camp program and its activities

List specific medical and food allergies and/or medical conditions:


Emergency Contact for Adult:



IF PARTICIPATING IN HORSEBACK RIDING: 

     I understand the unpredictable nature of a living creature such as a horse and that there are certain risks to personal health involved with the participation in an activity such as horseback riding. I further understand that Victory Ranch and Brotherhood Mutual Insurance Company both require the use of a helmet for all participants. I understand by signing this waiver I am releasing Victory Ranch; its board, director, employees, and volunteers; and Brotherhood Mutual of any responsibility should I suffer any injury while participating in a horseback ride at Victory Ranch. Knowing this, I agree to hold Victory Ranch and its staff harmless should I be injured while participating in horseback riding at Victory Ranch.

Sign below ONLY if you are choosing NOT to wear a helmet:

     I, being at least 18 years of age or older and participating in a horseback ride at Victory Ranch, have opted not to wear a helmet. I understand by signing this waiver I am releasing Victory Ranch; its board, director, employees, and volunteers; and Brotherhood Mutual of any responsibility should I suffer a head injury while participating in a horseback ride at Victory Ranch.

If minors, age 17 and under, will be attending the Retreat, please complete this next section.

VICTORY RANCH
Parental/Guardian Consent & Medical Release
(for minors, age 17 and under)

     I, the undersigned, do hereby give permission for my (our) child, to attend and participate in all activities, including horseback riding, with South Shores Church on November 15-17, 2024, at Victory Ranch. I (We) understand and agree that participation presents known and inherent risks to the participant and may result in injury, illness, exposure to infectious/communicable disease, death, and/or other damages.
     I (consent to an x-ray examination; anesthetic; medical, surgical, or dental diagnosis or treatment; and hospital care to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility, whether such diagnosis or treatment is rendered at the office of the said physician or at said hospital. I (We) do herewith authorize the treatment by this authority, and it is granted only after a reasonable effort has been made to reach me (us), the parent(s) or guardian(s). I (We), the undersigned, understand that I (we) am responsible for my (our) child’s medical obligations and shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned minor pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or otherwise, I (we) shall assume all transportation costs. My (our) signature below serves to indicate my (our) willingness to take full financial responsibility for any and all medical service rendered for the named participant. My (our) signature also serves to indicate my (our) willingness for the Health Insurance Company named below to be billed for any and all medical fees and services required. I (We) hereby release Victory Ranch from this liability.
     I, the undersigned, do hereby release and agree to hold harmless Victory Ranch and its directors, board, agents, employees, volunteers, and representatives from any and all liabilities or claims for personal or emotional injury, illness, exposure to infectious/communicable diseases, and/or death, as well as property damage and/or expenses of any nature whatsoever which may be incurred by my (our) son/daughter that occur within the effective dates stated above and/or while said minor is participating in the above named camp program and its activities.




Emergency Contact for Minors:

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