Cascade Christian Schools Trip Release and Agreement

811 S21st St. SE Puyallup, WA 98372 Phone: 253.445.9706 Fax: 253.445.0859 Name of Trip Cascade Christian Schools Trip Release and Agreement I, (first and last name), a participant in Cascade Christian Schools I- Term program for 20, do voluntarily and without reservation and behalf of myself, my heirs and my estate, waive any and all claims of whatever nature for any injury, loss, damage, accident, delay, irregularity or expense arising from the use of any vehicles or services, strikes, war, weather, sickness, quarantine, government restrictions or regulations, or from any act or omission of any steamship, airline, railroad, bus, transportation, sight-seeing, hotel or any other service or transportation company, firm, individual or agency, or for any other cause whatsoever in connection therewith against Cascade Christian Schools, my school or college, or any staff member or chaperone accompanying this program, their heirs or their estate. I agree that Cascade Christian Schools reserves the right to make cancellations, changes or substitutions in the event of emergencies, or changed conditions such as wars, strikes, weather, government restrictions or acts of God. Cascade Christian Schools reserves the right to make alterations in part or in all of the entire program for which cancelled can be made only of those funds not actually used or committed. The amount of said funds, in each individual case, shall be determined by Cascade Christian Schools. Also, I agree that Cascade Christian Schools reserves the right to alter, prior to program department, the cost in order to meet unexpected changes in airfares, lodging and food rates, etc. The announced fee is based upon current tariffs which are subject to change. I have read the above Release and Agreement statements and understand the same. Signature of Participant Signature of Parent or Guardian (if under 18) Please Notarize Below State of, County of Before me, the undersigned, a Notary Public in and for said county and state on, 20, personally appeared the identical person who executed the within and foregoing instrument, and acknowledged to me that he/she/they executed the same as his/her/their free and voluntary act and deed, for the uses and purposes therein set forth. Given under my hand and seal of office the day and year above written. Notary Public Resides in My commission expires: / /

811 S21st St. SE Puyallup, WA 98372 Phone: 253.445.9706 Fax: 253.445.0859 Cascade Christian Schools Student Mission/Educational Trip DOCTOR S RELEASE FORM ***Only to be completed if you had to mark yes to any of the questions in Section II on the Medical Information Form*** This form must be completed, signed by the examining physician, and returned with the trip application to Cascade Christian Schools. (Please print or type) Name: Last First Middle Examining Physician: Telephone: Physician s Address: To the Examining Physician The above named student is applying to participate in a mission or educational trip for the dates of and his/her trip may involve the following activities: 1. Construction work: including lifting, kneeling, stretching, hammering and painting. 2. Community work: including walking and standing for extended periods of time. 3. Childcare: including physical contact with children. 4. Food preparation. 5. Sleeping on the floor, cots or air mattresses. Based on my physical examination I conclude the above named person: ( ) is able to participate in the physical activities described above. ( ) is not able to participate in the following physical activities as described above. Please list Physician s Signature Date

Cascade Christian High School POLICY FOR OBEDIENCE TO SCHOOL/LEADER RULES 2015 Trip Group Leader s Name: Traveler s name There is an expected level of behavior and personal responsibility that is involved with individuals participating in Cascade Christian sponsored trips. In order to participate in this trip, participants, their legal guardians and/or parents must agree to adhere to all school and group leader rules. Please be advised that if a participant chooses not to abide by these rules, they will be responsible for the financial cost that may be incurred to return the traveler home. If a problem arises that is serious enough in nature to warrant the participant s removal from the travel group, parents/guardians will be notified by phone. This removal decision will be made by the accompanying Group Leader and the Tour Director, after the student has had an opportunity to respond to any allegations. Depending on the severity of the infraction, the student may also be subjected to further discipline upon return home in accordance with school policy. By signing below, you acknowledge this statement and agree to the listed provisions; thus participating students and parents cannot legally hold the Group Leader or tour company responsible in any manner for the actions or poor choices made by the participant. As a parent/guardian you must sign this form acknowledging that all school rules apply while on this trip and that no travelers are permitted to consume alcohol of any kind for the duration of the trip. Travelers are subject to all local laws and any rules established by the Group Leader. Parent section I understand that the above named traveler must follow all school rules and may not consume alcohol while on tour even if permitted by the local culture. I further understand that if the traveler does not abide by this rule, school rules in general, or any other rules stipulated in the Explorica or Cascade Christian Release and Agreements that the Group Leader can send the traveler home at parent s expense. Parent/Guardian Name Parent/Guardian Signature Date Traveler section As the traveler, I agree to follow the above agreement made by my parent/guardian regarding trip rules and alcohol consumption on my Cascade Christian/Explorica tour. I fully understand the potential consequence of being sent home at my parent/guardian s expense if I do not comply with these rules, school rules, or any other rules outlined by my Group Leader. Student Name Traveler Signature Date

MEDICAL INFORMATION Student s Name In Case of emergency, please contact: 1. Name Home Phone Address, City, State, Zip 2. Name Home Phone Address, City, State, Zip Childhood Immunizations (These must be up-to-date. Please do not leave blank.) Yes No Type Year Administered Yes No Type Year Administered MMR Tetanus DPT Other Polio Please complete the following questions: Are you currently taking any prescribed medications? Yes No If yes, please specify the medication and the dosage: Are you currently using any non-prescription drugs on a regular basis such as antihistamines or sleeping aids? Yes No If yes, please specify: Have you ever received treatment or counseling for alcohol or drug abuse? Yes No If yes, please specify when and where: Are you presently under a physicians care for any illness? Yes No If yes, please explain: What was the date and who was the physician of your last physical exam? List all surgical operations or hospitalizations you have undergone: Operations and/or Illness Reason Date Name and address of hospital Name of Physician Remaining Affects Operations and/or Illness Reason Date Name and address of hospital Name of Physician Remaining Affects SECTION II ALL QUESTIONS MUST BE ANSWERED. MISREPRESENTATION WILL VOID YOUR ACCEPTANCE. In the past 5 years, have you been treated by a doctor for any of the following: (Every item must be checked.) Yes No Yes No Asthma or chronic wheezing Serious bodily injury Emphysema, lung or respiratory problems Parkinson s Disease Chronic, persistent cough or shortness of breath Tuberculosis Any skin disorder or disease other than acne Gall bladder stones or colic Diabetes or hypoglycemia (low blood sugar) Chronic/recurrent ear or eye problems Cancer Jaundice, cirrhosis, or other liver problems Impairment of hearing or vision, Menier s Disease, cataracts or glaucoma High blood pressure, heart murmurs or other cardiac problems Intestinal or bowel problems, colitis, diverticulitis, hemorrhoids, other rectal problems or bleeding Severe migraine headaches Albumin, blood or pus in the urine; painful or frequent urination, or kidney problems Persistent, recurring indigestion, stomach or duodenal ulcers Rheumatism, gout, arthritis or other forms of swollen painful joints Any test results indicating exposure to the Aids virus Chronic back pain, back injury, or surgery, sciatica, scoliosis or other bone or joint disorder Fainting spells, dizziness, convulsions, epilepsy or seizure disorder Severe knee injury or problems Cysts, tumors or growths or any kind, hernia or rupture Abnormality of reproductive systems, prostate problems Mental health counseling or psychiatric treatment Breast disorder, menstrual disorder or venereal disease Vein or circulatory trouble Severe allergic reactions to either food, medications, bee stings or any other kid of insect bits Anemia or other blood disorders Any other disease, deformity or disability not listed above Goiter, thyroid ailment, high or low metabolism **** PLEASE NOTE THE FOLLOWING: If you checked no to ALL the questions in Section II then you are NOT required to complete the provided doctors release form. If you checked yes to ANY of the questions in Section II you ARE required to: 1. Visit your Doctor 2. Have him/her complete and sign the doctor s release form provided **** YOUR ACCEPTANCE WILL BECOME VOID IF THESE STEPS ARE NOT FOLLOWED.

Consent for Medical Treatment: Release and Hold-Harmless for Travel Whereas, (my child) wish/es to be a member of a Cascade Christian Schools Student Ministry or Educational team which will be traveling to and staying in (state/country), and whereas, certain circumstances may occur resulting in (my child s/my) need for medical/dental care and treatment and further resulting in my inability to personally give consent for such care and treatment; therefore, in consideration of permission for (my child/myself) to participate in said mission or trip, I,, being of legal age, authorize Cascade Christian Schools or any agent of Cascade Christian Schools to act on (my child s/my) behalf should I be unable to do so, and to consent to reasonable medical/dental care and treatment including but not limited to diagnostic test, x-ray examination, anesthesia, surgery, or other procedures which may be deemed necessary for (my child s/my) medical well-being for the duration of the mission trip. This consent is given in advance of any specific diagnosis, treatment, surgery, or hospital care required, but is given to provide authorization and specific consent for medical/dental treatment and care in (my child s /my) behalf. Any consent by Cascade Christian Schools shall have the same force and effect as if I had personally given the consent. I certify I have personal health insurance with no territorial limitations, including foreign countries, which will provide coverage for (my child/me), during the duration of said mission. I understand no health plan is provided by Cascade Christian Schools. Company (Must provide proof of Medical insurance (Copy Attached). Policy Number I certify I am award that Cascade Christian Schools doesn t provide an insurance policy and I understand by not having a personal policy with no territorial limitations, I will personally be responsible for any extra cost that (my child/myself) may cause the team or Cascade Christian Schools. I am aware that serious illness requiring return by air ambulance, could cost more than $10,000. I agree I am solely responsible for any expenses which arise from (my child s/my) return by air ambulance, or other extraordinary means. I hereby release and hold harmless Cascade Christian Schools, it s officers, employees, and representatives/volunteers from all liability for personal injury, including death, as well as all property damage or loss arising out of (my child s/my) participation in this trip. I have read and understand the above information. This information I have given Cascade Christian Schools is accurate and true to the best of my knowledge. I also give Cascade Christian Schools the right to use my picture, voice, or testimony in any form of promotional or advertising materials. My enclosed signature signifies my approval of all limitations above. If you are under custody of both parents, both parent s signatures are required to be notarized. If you are under custody of one parent, the signature of the one whom has custody is required to be notarized. X Father s/guardian s Signature X Mother s/guardian s Signature X Student s Signature (This section to be filled out by a notary) State of, County of. Before me, the undersigned, a Notary Public in said county and state on, 20, personally appeared the identical person who executed the within and foregoing instrument and acknowledged to me that he/she executed the same as his/her free and voluntary act and deed, for the uses and purposes therein set forth. Given under my hand and seal of office the day and year written above. Notary Public Resides in Commission Expires Honor Code Recognizing Jesus as the author and finisher of my faith, and the Word of God as the supreme standard for all wisdom and knowledge, it is my aim to develop myself accordingly, realizing that as I seed first His kingdom and righteousness, all these things will be added unto me. It is my desire to develop myself as a servant and to seek opportunities to serve, realizing that love exalts and prefers others to self. I will endeavor to follow the will of God for my life and to exemplify Christ-like character through daily personal prayer, consistent study of the Word of God, and faithful group worship. I will endeavor to faithfully give heed to: th3e call God has on my life; to develop the gifts and abilities that God has given me. I will endeavor to bring glory and honor to the name of Jesus through my ministry and allow the love of the Spirit to flow through me. I will submit myself to the established leadership of Cascade Christian Schools and/or to any rules or regulations that may be adopted or changed from time to time. I realize my participation as a member is a privilege and a call from God, not a right. I purpose to give my best and to positively support the ministry of Cascade Christian Schools As part of this team, I take the Great Commission as a personal call on my life. It is my aim to spread the Good News and make the most of every opportunity to minister. Discipline Agreement The rules and regulations of Cascade Christian Schools are expressly designed to ensure the safety and well being of each team member and to main the high degree of Christian integrity required to minister effectively in cross-cultural settings. The enforcement of all aspects of these rules and regulations are the responsibility of the Cascade Christian Schools staff which includes the Trip Coordinator, and Adult Chaperones. Enforcement shall occur in a manner they feel is in accordance with Christian principles and the stated purpose of the project. We expect full cooperation from members (and parents if applicable) in disciplinary decisions made. The discipline committee reserves the right to send any team member home who shows disregard for the stated rules and regulations. The team member and/or his family are responsible for any cost involved in sending a team member home. The costs may include, but are not limited to, airfare, hotel room, and food. We have read the Rules and Regulations as stated and agree to abide by them. X X Student s Signature Date Parent s Signature Date