Excursion Trip 7th-12th

 EXCURSION TRIP
Times & Tidbits
Pleasant Hill Outdoor Camp
4654 Pleasant Hill Rd.
Perrysville, Ohio 44864
419‐938‐3715
www.phoc.org
When is my final Payment due?
Final payment is due by first day of child’s camp session. You may pay on our website, mail check or pay by phone.
What should I do prior to check‐in to speed up the process?
Make sure that your balance is paid in full and all camp forms have been returned prior to arrival.
When & where is drop off and pick up?
PA Excursion campers will need to arrive at 1 pm on Sunday for check‐in as vans will depart promptly at 1:30 pm.
Please be sure to have all forms filled out and returned to our office prior to departure day.
Pick‐up will be on main campus between 5:00 and 5:30 pm on Thursday.
What if my child takes medica on?
Special instruc ons should be given to our camp nurse during check‐in for those taking medica ons or those with
special medical or dietary needs. At that me the camper will turn in any meds to the Camp Nurse/TLC. All meds
should be in original packaging or prescrip on bo le and will be administered as prescribed by physician. Also,
please be sure to fill out your PRN Medica on Form. Medica ons should be picked up at check out.
Will my camper need to bring cash?
If your camper would care to bring cash, we will be making a few stops during the trip and they are welcome to
purchase refreshments or souvenirs.
Lost & Found
It is your child’s responsibility to keep track of his or her belongings. All items le behind will be disposed of or
donated to charity at the end of each session.
Excursion Trip
What to bring list...
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Recommended Clothing & Items
Sneakers
T-shirts
Long Pants-2 pair
Shorts
Underwear
Socks
Appropriate swimsuit
Shower Shoes/flip flops
Pajamas
Cap or Hat
Poncho or Rain Jacket
Sleeping Bag
Sleeping Pad
Pillow and extra pillow case
Bug Spray/Repellant is a must
Fleece or Jacket & Hat for cool evenings/mornings
Water Bottle
Day Pack/String backpack
Bath Towels
Beach towel
Soap & Shampoo
Toothbrush/Toothpaste
Comb/Brush/ Hair ties
Bible/Notepad/Journal (optional)
Camera
Sunscreen/Bug Spray/Flashlight
2 sources of Light– Headlamp & Flashlight
Kneepads
Sturdy Hiking Shoes/ Boots
Rain Gear
Cash for road trip snacks
Water proof Sunscreen for River Trip
****Release Forms for River
Camp Dress Code
Pleasant Hill Outdoor Camp 4654 Pleasant Hill Rd. Perrysville, Ohio 44864 www.phoc.org Office: 419-938-3715
Fax: 419-938-3714
Exec. Director: Ben Radley [email protected] Program Director: Jordon Steiner [email protected] At Pleasant Hill Outdoor Camp, we want you to have the best possible experience. Accordingly, for the good of all, we have a dress code for all campers and staff. By planning ahead and packing appropriately, you will help contribute to a pleasant camp atmosphere for everyone. Please be advised that the following dress code applies to all individuals a ending the camp, including staff and counselors. All clothing should be worn within the bounds of decency and good taste as appropriate for camp events. To that end: 1. Ar cles of clothing which display profanity, products, or slogans which promote tobacco,
alcohol, drugs, sexuality or are in any other way distrac ng, are prohibited.
2. Excessively baggy or ght clothing, and clothing which adver ses gang symbols or affilia on
is prohibited.
3. Items of clothing which expose areas tradi onally considered private such as midriffs, chests
and undergarments, or that is transparent (see through) are prohibited. Tank tops with straps
wider than one inch are permi ed. Please be advised that spaghe straps, shirts which expose
a bare back , halter tops, and tube tops are prohibited.
4. Swimming (for all water recrea on):
Swim trunks only for men (No Speedos)
One-piece suits for women recommended, however, two-piece suits are allowed when worn
with a dark colored t-shirt. Shorts and shirts are permi ed as well.
Those who fall outside of the above guidelines will be asked to change. Thank you for helping us maintain a camp environment that is healthy and enjoyable for all! Sincerely, PHOC Staff PHOC
Alpine Adventures
A Ministry of Appalachian Bible College
161 College Dr., Mt. Hope, WV 25880
(304) 877-6427
(800) 806-2180
FAX (304) 877-5046
alpineretreats@abc,edu
RELEASE AND ASSUMPTION OF RISK FORM FOR ADVENTURE RECREATION
I, the undersigned, am aware that during the adventure trips described in this form and in which I am participating, under the
arrangements of Alpine Adventures and its parent organizations, Alpine Ministries, Alpine Bible Camp and Appalachian Bible College,
its agents, employees, and associates, certain risks and dangers may be present or occur, including but not limited to the outlined risks
following;
WHITEWATER RAFTING / WHITEWATER DUCKIES / CANOES
I am aware that during the river trip in which I am participating under the arrangements of Alpine Adventures, that certain risks
and dangers may be present or occur, including but not limited to, hazards of traveling on a rubber raft or canoe with paddles, oars, and
other equipment in rough river conditions, falls onto such equipment or into the river, swimming in the river, falls or slips while walking,
hiking, or climbing on terrain that is not improved, participation in water activities and water fights, accidents or illness in remote places
without medical facilities, injuries by reptiles, insects or other animals, the forces of nature, and travel by automobile, van, bus, or other
conveyance. Participants rafting on the Upper New River must be age 8 or older. Participants rafting on the Lower New River must be
age 13 or older. Participants on the Lower Gauley River must be age 14 or older. Participants rafting on the Upper Gauley River must
be age 16 or older and must possess excellent swimming ability.
HIGH CHALLENGE ACTIVITIES / LOW ELEMENT TEAMBUILDING
I am aware that during the climbing and rappelling trip, use of the high ropes course, low element teambuilding, climbing walls,
swings, or zip wires, in which I am participating under the arrangements of Alpine Adventures, that certain risks and dangers may be
present or occur, including but not limited to, hazards of falling from heights, rope entanglement, falling rocks and other debris, burns or
injuries related to the handling or use of ropes and other climbing equipment, falls or slips while walking, hiking, or climbing on terrain
that is not improved, accidents or illness in remote places without medical facilities, injuries inflicted by reptiles, insects or any other
animals, the forces of nature, and travel by automobile, van, bus, or other conveyance. Participants in the high challenge activities
must be age 12 or older.
CAVING
I am aware that during the caving trip in which I am participating under the arrangements of Alpine Adventures, that certain
risks and dangers may be present or occur, including but not limited to, hazards of underground exploration in a cave, holes, crevices,
and passageways, falling rocks and cave-ins, entrapment, falls or slips while walking, hiking, or climbing on terrain that is not improved,
accidents or illness in remote places without medical facilities, injuries inflicted by reptiles, insects or other animals, the forces of nature,
and travel by automobile, van, bus, or other conveyance. Participants must be age 12 or older.
PAINTBALL
I am aware that during the paintball activity in which I am participating under the arrangements of Alpine Adventures, that
certain risks and dangers may be present or occur, including but not limited to, accidents or injuries related to the use and handling of
paintball equipment, hazards of being bruised when struck or marked by a paintball, falls or slips while walking, running, crawling or
climbing terrain that is not improved, accidents or illness in remote places without medical facilities, injuries inflicted by reptiles, insects
or other animals, the forces of nature and travel by automobile, van, bus, or other conveyance. Participants must be age 12 or older
and must agree to wear all safety equipment including helmets and face shields at all times.
HIKING / WILDERNESS CAMPING / BACKPACKING
I am aware that during the hiking, wilderness camping or backpacking trip in which I am participating under the arrangements
of Alpine Adventures, that certain risks and dangers may be present or occur, including but not limited to hazards of falls or slips while
walking, hiking, or climbing on terrain that is not improved, accidents or injuries related to the use and handling of camping and
backpacking equipment, accidents or illness in remote places without medical facilities, injuries inflicted by reptiles, insects, or any other
animals, the forces of nature, and travel by automobile, van, bus, or other conveyance.
CONTINUED ON OTHER SIDE
In consideration of and as part payment for the right to participate in such adventure recreation, other activities,
use of recreational facilities, and the services and food, if any, arranged for me by Alpine Adventures, its agents,
employees, and associates, I have and do hereby assume all of the above hazards and other related risks which may be
encountered on said adventure recreations including activities preliminary and subsequent thereto, and I do hereby hold
Alpine Adventures, its agents, employees, and associates harmless from any and all liability, actions, causes of action,
debts, claims and demands of every kind and nature whatsoever which I now have or which may arise from, or in
connection with my adventure recreation or participation in any other activities related thereto.
I hereby irrevocably consent to and authorize the use and reproduction by Alpine Adventures, or anyone
authorized by Alpine Adventures, of any and all photographs which may be taken during the adventure recreation in which
I am participating or other activities related thereto, for advertisement or promotional purposes, without further
compensation to me. All negatives and positives, together with the prints shall constitute property of Alpine Adventures or
those authorized by Alpine Adventures to take pictures or videotapes, solely and completely.
I further agree to obey and follow all rules, regulations, and instructions of Alpine Adventures, its agents,
employees, and associates. The terms hereof shall serve as a release, indemnification, and assumption of risk for my
heirs, executors and administrators and for all members of my family, including any minors accompanying me. This is a
legally binding document, which I have read and understand. A Parent or Legal Guardian must give permission for all
persons under age 18.
X________________________________________________
DATE: _______________________ AGE: __________
(Signature of Participant)
PLEASE PRINT THE FOLLOWING INFORMATION:

Name of Participant

Home Address
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City
  -- --
State
Zip Code
Home Telephone Number
Complete Date of Birth
PARENT OR LEGAL GUARDIAN PERMISSION FOR MINORS
I hereby certify that I am the parent or the court-approved legal guardian of the minor who has signed above. I
hereby grant such minor permission to participate in the adventure recreation and other activities provided by Alpine
Adventures, and in such minor's behalf, I hereby agree to all of the terms of the RELEASE AND ASSUMPTION OF RISK
FORM FOR ADVENTURE RECREATION printed above as if such were fully written here.
X___________________________________________________  Parent
OR
 Court-­‐approved Legal Guardian
(Signature of Parent or Court-approved Legal Guardian)
DATE: __________________________
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ext.
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Work / Additional Phone Number
Page 2 of 2
Revised: 08/14/10
CONTRACT & LIABILITY WAIVER & INDEMNIFICATION AGREEMENT
I am aware that during the river or mountain biking trip (and associated base camp or other activities
such as lodging, camping, kayaking, mud obstacle course, hiking, swimming, horse riding, climbing,
zip line tours, caving, ropes course, paint ball, snow tubing, ATV, lake activities, including Aqua-Jump,
etc, in which I am participating under the arrangement of American Canadian Expeditions, Ltd., dba
ACE Whitewater, aka ACE Adventure Resort, Wildwater Expedition Unlimited or North American River
Runners (and/or associated companies including but not limited to: Mountain Cove, Inc., Adventure
Expeditions, Inc., Riverworks, Inc., Gauley Outdoor Center, Inc., Equestrian Adventures, BridgeWalk,
Burning Rock), their agents, employees, associates, and equipment manufacturers, certain substantial risks and dangers may occur, including, but not limited to:
• hazards of traveling on a raft, canoe or kayak in normal,
rough or flooded river conditions
• hazards of walking on railroad tracks (trains can be hard
to hear in river gorges),
• attacks from wild or domesticated animals,
• hazards of jumping, diving or being thrown into
unfamiliar water with submerged hazards,
undercut rocks, and man made hazards,
• hazards of rafts flipping or dumping guests
• hazards of long, cold swims,
• hazards of being pinned under and/or against trees,
rocks, rafts or other objects,
• contact with paddles, helmets, other guests or guides,
food boxes or other containers,
• diseases from contaminated water,
• allergies from cleaning reagent,
• hazards of hiking, biking, horseback or ATV
riding in rough terrain,
• disease,
• strains or sprains,
• fractures or punctures,
• partial and/or total paralysis,
• loss or damage to personal property,
• snake bites, insect bites and bee stings, (the above listed
companies rarely carry
medications),
• illnesses, or injury in remote places without medical facilities,
• failure of or lack of communication equipment,
• failure or lack of safety equipment,
• injuries occurring in rescue operations (rafts may bump
other rafts, ropes may cause
entanglements, rocks may be slippery),
• entrapment in caves,
• falls from man-made and natural cliffs,
• hazards of entering and leaving the raft,
• hazards of loading or unloading people or
materials from vehicles,
• hazards from the force of nature,
• falling limbs or trees,
• problems or hazards related to travel by
automobile, bus, ATV or other conveyance
(vehicle accidents),
• problems or hazards related to consumption of
alcoholic beverages by anyone,
• being struck by falling people,
• death,
• accidents,
• drownings,
• entrapment in rafts,
• slippery mud,
• eye injuries including blindness,
• equipment malfunction (paddles may break, rafts may
come apart, etc.),
• frostbite or other cold related injuries,
• heat stroke, sunburn,
• briers and thorns,
• lightning,
• explosions (gas grills),
• fresh water amoeba infection,
• criminal acts,
• falls from elevated ropes, platforms or other structures or
features
• falls from horses and bicycles
and that these risks and dangers may be caused by the negligence of the owners, employees,
officers or agents of the above listed companies, negligence of others, accidents, breaches of
contract, the forces of nature or other causes. These risks and dangers may arise from
foreseeable or unforeseeable causes including that a guide may misjudge terrain, weather,
trail or river route location or water level and may be unaware of your fitness or abilities. Staff
may give incomplete warnings or instructions. Decisions by guides or company staff are part
of the inherent risk of rafting and of other activities. In consideration of and as part payment
Any alteration to this waiver will prohibit the participation in all activities.
PAGE 1 OF 4 PAGES (READ & RETURN ALL 4 PAGES)
for the right to participate in such river and land activities and the services, food and alcoholic
beverages, if any, arranged for me by the above listed companies, its agents, employees and
associates, I have and do hereby assume all of the above risks, and release, and will hold
harmless, the above listed companies, their agents, employees, associates and associated
companies, or any other person from any and all liability, actions, causes of action, debts, claims
and demands of every kind and nature whatsoever which I now have or which may arise out of or
in connection with my trip or participation in any of the base camp or related activity. I further give
permission for use or sale of any photograph or video showing me without further compensation to
me. The terms hereof shall serve as a release, contract, indemnification (allowing collection of legal
fees from plaintiffs), indemnification by parents or guardians (reimbursement of awards and legal
fees in a winning suit brought by the minor or other parent), and assumption of risks for my heirs,
executors and administrators and for all members of my family, including, minor’s parents, any
minors accompanying me.
I certify that I will not hold the above listed companies, their agents, employees or associated
companies responsible for actions of independent or quasi-independent providers of activities
which have been arranged for me by, or recommended to me by the afore listed entities. I am
participating for enjoyment or thrills and understand that the activities require physical exertion
and involve a challenge containing a potential risk of injury or death.
I certify that I will not hold any of the above listed companies, their agents, employees or associated
companies responsible for any harm occurring wholly or partially as a result of any existing health
problems including, but not limited to:
• reactions to bee stings or the constriction of airways due to cold weather or asthma,
• broken bones due to osteoporosis,
• hemophilia,
• heart disease,
• high blood pressure,
• pregnancy,
• loss of stamina or coherency due to diabetes.
If medical evacuation, including ambulance, Hi-railer, helicopter, due to new or existing medical
conditions is arranged by the above listed companies, I agree to reimburse the above listed
companies for any charges.
I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may
have presently or in the future for the negligent acts or other conduct by the owners, agents, officers
or employees of the above listed companies.
This is a public area in which only minimal security may be provided; the same precautions against
crime should be exercised here as anywhere else.
The venue of any dispute that may arise out of this agreement or otherwise between the parties
to which the above listed companies or their agents is a party shall be the Fayette County Court in
Fayetteville, WV. If any portion of this contract and release is found to be invalid, the remainder shall
remain in full force.
I HAVE READ THE ABOVE WAIVER AND RELEASE/CONTRACT AND BY SIGNING IT AGREE IT
IS MY INTENTION TO EXEMPT AND RELIEVE THE ABOVE LISTED COMPANIES &
EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL
DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE. I RECOGNIZE THAT I AM FREE
NOT TO PARTICIPATE IN ANY ACTIVITIES.
PAGE 2 OF 4 PAGES (READ & RETURN ALL 4 PAGES)
PARTICIPANT RESPONSIBILITIES
The West Virginia Whitewater Responsibility Act (WV Code 20-3B-1 through 5) imposes the following
duties on participants in whitewater expeditions:
(a) Participants have a duty to act as would a reasonably prudent person when engaging in
recreational activities offered by commercial whitewater guides in this state.
(b) No participant may:
(1) Board upon or embark upon any commercial whitewater expedition when intoxicated or under
the influence of non-intoxicating beer, intoxicating beverages or controlled substances; or
(2) fail to advise the trip leader or the trip guide of any known health problems or medical
disability and any prescribed medication that may be used in the treatment of such health
problems during the course of the commercial whitewater expedition.
(3) Engage in harmful conduct or willfully or negligently engage in any type of conduct which
contributes to or causes injury to any person or personal property; or
(4) perform any act which interferes with the safe running and operation of the expedition,
including failure to use safety equipment provided by the commercial whitewater outfitter or
failure to follow the instructions of the trip leader or trip guide in regard to the safety measures
and conduct requested of the participants; or
(5) fail to inform or notify the trip guide or trip leader of any incident or accident involving personal
injury or illness experienced during the course of any commercial whitewater expedition. If
such injury or illness occurs, the participant shall leave personal identification, including
name and address, with the commercial whitewater outfitters’ agent or employee.
I understand that the Responsibility Act immunizes the outfitter from tort (legal) actions as long as the
industry standard of care is met.
Zip Line Weight Statement:
I HAVE BEEN MADE AWARE OF THE ZIP LINE WEIGHT REGULATIONS
AND AM STATING I WEIGH WITHIN THE 70-250 LBS REQUIREMENT .
______________(INITIALS)
West Virginia Bicycle Riders’ Responsibility:
1. West Virginia state law requires all bicyclists fifteen years of age and under must
wear a helmet. ACE requires that ALL riders wear a helmet.
2. Participants are responsible for all issued rental equipment including but not limited
to damage to bicycle and its corresponding components and helmets. A credit card
or other collateral will be held with rental form to cover any damage expenses.
3. The trail map is a general guide only and is not to scale. ACE cannot be held
responsible for inaccurate information or the condition of the trails.
4. All rented equipment will be returned and checked back in at the specified time. If I
fail to return by the specified time, I will be charged for the additional time. I agree to
wash the bike when I return. After proper return, collateral items will be charged
or returned.
5. For rental bikes, the adventure center does not provide shuttle service. In the event
that I become lost or the bike breaks down while riding and I request a pick up, and
if driver & vehicle is available, then I will be responsible for any and all expenses that
incur. If I do not return the bike to the Bike Check Out Area, I agree to pay for the
replacement cost.
I HAVE BEEN ISSUED A HELMET AND AGREE TO WEAR IT AT ALL TIMES
WHILE BIKING. ______________(INITIALS)
PAGE 3 OF 4 PAGES (READ & RETURN ALL 4 PAGES)
PLEASE COMPLETE ALL INFORMATION
YOUR INFORMATION ( All fields must be completed.)
l
FIRST NAME
LAST NAME
ADDRESS (Has your address changed since your last visit to ACE?
MALE
l
FEMALE
l Yes l No)
CITY
STATE
HOME PHONE
DATE OF BIRTH
-
-
-
ZIP
BEGINNING DATE OF ACTIVITY
-
-
-
EMAIL ADDRESS
@
Would you be interested in receiving an e-mail newsletter containing discounts and specials? l Yes
l No
PERSON IN YOUR PARTY THAT MADE YOUR RESERVATION
FIRST NAME
LAST NAME
EMERGENCY CONTACT INFORMATION (Please list someone that is not on this trip with you.)
FIRST NAME
LAST NAME
RELATIONSHIP TO YOU
PHONE NUMBER
Do you have any health related issues that could affect you or other persons on the
trip that you would like to discuss with the trip leader? (Ex: bee stings, allergies,
asthma, heart problems, prescribed medications, injuries, etc.) l Yes l No
• I agree to personally inspect my helmet, personal flotation device and paddle for any
defects before leaving the base camp.
• The above listed companies do not carry medical insurance.
• I have read and agree to all the terms in this four (4) page contract.
_____________________________________________________________
Signature of Participant (All participants, including minors, must sign here.)
We, the parents or legal guardians, hereby certify that we have discussed the risks with
our child and our child fully understands and comprehends ALL the risks.
____________________________________
____________________________________
Signature of both parents/guardians if participant is less than 18 years of age.
NOTE: Waivers from other organizations cannot be used in place of this waiver. Group
leaders can not sign in place of parent or guardian, even with written permission.
PAGE 4 OF 4 PAGES (READ & RETURN ALL 4 PAGES)