fyi.......this is last year's schedule. The medical release form and the Camp Kern risk form will be the same for our 2009 event.
2008 LYO EVENT SCHEDULE
Friday night
6:30-8:00 Registration
8:00 Peter Eide
8:30 Announcements, welcomes, introductions
8:45 Gone Fishing
9:05 Small Group Time (Victor Thomas)
10:05 Meet with church group for reflection time
Saturday
8:00 Breakfast
9:00 Peder Eide
9:30 Gone Fishing (Logan Dysart)
9:50 Break
9:55 Small Group Time
10:55 Workshops
12:00 Lunch
1:00 Workshops
2:00 Small Group Time
3:00 Peder Eide
3:30 Gone Fishing (Gary Eichhorn)
4:00 Elections
5:30 Dinner
6:30 Small Group Time
7:30 Peder Eide
8:00 Talent Show
Dance to follow the talent show
Sunday
8:00 Breakfast
9:00 Announcements and Peder Eide
9:30 Worship
10:45 Cabin Checks
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DETAILS:
Cost: $100 per person if deposit paid by September 30, 2008 or $120 if paid after September 30, 2008.
Registration fee includes: lodging, breakfast, lunch & dinner on Saturday and breakfast on Sunday, plus t-shirt for those registered prior to 9/30! For evening snacks - each participant should bring one bag of snacks to share, soda and water provided.
REGISTRATION DEADLINE: September 30, 2008 Please include: completed group registration, individual health/permission forms for each participant and Camp Kern form, check made payable to SOSLYO and mail to: Casey Backus, Camp Mowana, 2276 Fleming Falls Rd, Mansfield, Ohio 44903
GROUP REGISTRATION:
Church________________________________________
Primary Leader _________________________________
Address_______________________________________
______________________________________________
Phone____________________ Email (for updates)______________________
# Female Youth___________________ # Male Youth_____________________
#Female Adults___________________ # Male Adults____________________
Total Number ____________________
$100 per person prior to 10/31 and $120 after 10/31
1/2 of amount due by 12/1/07
Total Submitted $_____________________________
T-shirts
Small_____ Medium_____ Large _____ X-Large_____ XX-Large_____ XXXLarge____
TOTAL Number of T-shirts_________________
Questions? Contact...................
Casey Backus: (419)589-7436 email: Mowana@lomocamps.org
Robin Kaelin (513) 284-5176 email: rkaelin6358@yahoo.com
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YMCA CAMP KERN ACKNOWLEDGEMENT OF RISKS
ASSUMPTION OF RISK AND RESPONSIBILITY AND RELEASE OF LIABILITY
PLEASE READ CAREFULLY
Although precautions are taken to provide proper organization for your participation in our program, there can be no guarantee about absolute safety against injury and unforeseeable accident. There are elements of risk in any adventure, sport, or program involving physical exertion and risk taking, or associated with the outdoors (referred to herein as "activity"), and the use of any equipment for the activity. I understand that I may be involved in activities including, but not limited to problem-solving, team building initiatives, ropes course, and/or other physical activities. I acknowledge that I may decline to participate in any activity. Any participation will be voluntary.
ACKNOWLEDGEMENT OF RISKS: I recognize the fact there is an inherent danger in any activity which involves physical exertion or risk taking; that natural hazards do exist; that although the program may be stenuous, injuries or medical complications may occur; that certain forseeable and unforseeable events unique to each individual activity can contribute to the unpredictability of the activity; that balance and physical coordination may affect the occurence of accidents or falls, and that I should ask about other potential hazards and recommend precautions and procedures.
EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: In recognition of the inherent risks of the activity which I and any minor children for which I am responsible, will engage in , I confirm that I am (we are) physically and mentally capable of participation in the activity and/or using equipment. I/we participate willingly and voluntarily and I assume full responsibility for personal injury, accidents or illnesses, including death. I also assume responsibility for damage to or loss of personal property as the result of any accident that may occur.
I assume the risk(s) of personal injury, accidents, and/or illnesses, including but not limited to, sprains, torn muscles, and/or ligament; fractured or broken bones; eye damage; cuts, wounds, scrapes, abrasions, and/or contusions; dehydration, oxygen shortage (anoxia), exposure and/or altitude sickness; head, neck and/or spinal injuries; animal or insect bite or attack; injury caused by discharge or any weapon; shock, paralysis and/or death; and acknowledge that during the activity, if I/we experience fatigue, chill and/or dizziness, it may diminish my/our reaction time and increase the risk of an accident.
COVENANT OF GOOD FAITH: I recognize that you, as provider of services, will operate under a covenant of good faith and fair dealing, but that you may find it necessary to terminate any activity due to forces of nature, medical necessities or other problems; and/or refuse to terminate the participation of any person you judge to be incapable of meeting the rigors or requirements of participating in the activity. I accept your right to take such actions for the safety of myself and/or other participants. I acknowledge that no guarantees have been made with respect to achieving objectives.
AUTHORIZATION: I hereby autorize any medical treatment deemed necessary in the event of any injury while participating in the activity. I will have appropriate insurance or, in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my/our behalf.
RELEASE: In consideration of services or property provided, I for myself and any minor children for which I am parent, legal guardian or otherwise responsible, any heirs, personal representatives or assigns do hereby release YMCA CAMP KERN its principals, directors, officers, agents, employees and volunteers, and each and every land owner, municipal and/or governmental agency upon whose property and activity is conduced, from all liability and waive any claim for damage arising from any cause whatsoever (except that which is the result of gross negligence).
Group Name ___________________ Participant Name ______________________
Participant Signature_______________________________ Date: ______________
If participant is under 18, a parent/guardian's signature is required: Parent/Guardian_______________________________________
MEDICAL RESTRICTIONS:___________________________________________
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2008 SOSLYO Youth Gathering
Individual Registration and Emergency Release Form for January 11-13, 2008
Camp Kern in Oregonia, Ohio
Church Attending With:_________________________________________________
Name of Participant:________________________________Age_____Gender_____
Parent/Legal Guardian:_________________________________________________
Home Address:______________________________Phone:___________________
City:_______________________________________________Zip:_____________
Home of Participant's Doctor:_________________________Phone:______________
Complete Address:____________________________________________________
Guardian's Insurance:__________________________________________________
Name of Policy Holder:_________________________________________________
Policy or Group Number:________________________________________________
Indicate current medication or medical treatments:_____________________________
___________________________________________________________________
___________________________________________________________________
List allergies, dietary concerns, or medical conditions:__________________________
___________________________________________________________________
___________________________________________________________________
Authorization for Treatment:
I hereby give permission to the medical personel selected by the Southern Ohio Lutheran Youth Organization to order x-rays, routine tests, and necessary transportation for my child. In the event I cannot be reached in an emergency, I give permission to the physician selected by the staff to secure and administer treatment, including hospitalization, for my child named above.
Signature of Parent/Guardian:____________________________________________
Permission:
I hereby give permission for my child to participate in all retreat/event activities except as noted above. Further, I give permission for use of photos of my child to be used in LYO promotion unless noted. My child will follow the rules of the retreat/event and the directions given by the staff.
Signature of Parent/Guardian:_____________________________________________
Basic Covenant
The covenant is a basic agreement for participants and adult advisors to ensure a safe, enjoyable gathering. All persons attending have been asked to sign this pledge. Groups are encouraged to decide upon other issues of importance for the congregation attending.
I pledge to conduct myself in a way pleasing to God, to represent my church and congregation with respect to others. I pledge not to use alcohol or illegal drugs, will not smoke if under 18, and will respect the property.
Signature of Participant:______________________________ Date:______________
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