Adult Registration Form
School Name _________________________ Teacher Name _______________________
Adult Name __________________________ Gender __________ Date of Birth ___________
Address __________________________________________________ City _______________ Zip __________
Home phone (____)_______________ Cell phone (____)_________________
Medical Insurance Company Name _______________________________ Policy # _______________________
Emergency Contact _______________________ Home phone (____) ___________________
Cell phone (____) _________________________ Work phone (____) ____________________
Adult Health & Diet Information (Please complete all sections, include additional page if needed)
Details of any Health Concerns that may arise at camp (ex. anxiety, sleep walking,…): __________________________
_________________________________________________________________________________________
Any Allergies (ex. food, drug, insects…): ______________________________________________________________
Regular Medications ________________________________________________________________________
Dietary Needs: Vegetarian Gluten-Free Other For any other dietary needs, you must complete &
submit two weeks prior to camp date, the Special Diet Info Form (available from your teacher or at www.missionspringsoe.com)
Mission Springs Outdoor Education will align with current state and county COVID-19 guidelines.
THIS RELEASE MAY LIMIT YOUR LEGAL RIGHTS. Mission Springs Camps and Conference Center, Inc. (hereinafter, “Mission Springs”), also known as Frontier Ranch,
offers an array of camp and conference services and facilities. While Mission Springs strives to operate safe programs and maintain safe facilities, there is always a
risk of injury when participants engage in activities involving physical exertion in the natural, dim, and rustic setting of Mission Springs. By signing below, I attest that I
have disclosed all known health conditions that may affect Participant’s participation in the Mission Springs camp or conference. Further, I acknowledge that
Participant is in good physical condition. I acknowledge that Mission Springs shall not be responsible for personal belongings that may be lost or stolen during a camp
or conference. In the event of an emergency, I hereby give permission to Mission Springs (and physicians selected by Mission Springs) to secure any medical
treatment that may become necessary, including injections, anesthesia, and/or surgery. I acknowledge that Participant has my permission to fully participate in
conference and/or camp activities, both on and off Mission Springs grounds, except as otherwise noted on the conference or camp application. I also give Mission
Springs permission to use Participant’s photo in future promotional materials. My signature below acknowledges that I, as a participant in a camp or conference to be
held at Mission Springs, and on behalf of my child (or other person over whom I hold a legal guardianship or conservatorship) who will participate in a camp or
conference at Mission Springs, am aware of the inherent hazards and risks associated with such participation. By signing below, I attest that I have a full
understanding of the inherent hazards and risks associated with participation in the conference or camp, including the activities included therein, which may involve
areas of poor lighting, rough terrain, and other natural and man-made elements that could result in injury, and hereby assume all risk of loss, damage or injury that
may be sustained by myself, my child, or other person over whom I have a legal guardianship or conservatorship. FURTHERMORE, I HEREBY RELEASE MISSION
SPRINGS AND ITS BOARD OF DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, AND/OR VOLUNTEERS FROM ALL LIABILITY, REGARDLESS OF WHETHER SUCH LIABILITY
STEMS FROM THE NEGLIGENT ACTS OR FAILURES TO ACT OF MISSION SPRINGS EMPLOYEES, AGENTS, DIRECTORS, OFFICERS, AND/OR VOLUNTEERS. The undersigned
agrees that the foregoing Release of Liability is intended to be as broad and inclusive as permitted by the laws of the state of California, and if any portion thereof is
held invalid, it is agreed that the balance shall, notwithstanding, remain in full force and effect.
Participant Signature ____________________________________ Date ____________
