2023 Breakaway Adult Family Member Application

Family Information

Please complete a separate application for each member of the family.

Primary Contact*

First Middle Last

List whom in the family will be the main contact for all applications submitted.

Family Position (Dad, Mom, Caregiver, etc.)

Family Member Contact Information

Legal Name*

First Middle Last

Preferred First Name*

Gender*

Male

Female

Date of Birth*

Month

Day

Year

Age*

Is Applicant Married

Yes

No

Primary Phone*

Secondary Phone*

Who do you live with?*

Mom

Dad

Mom & Dad

Other

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Emergency Contact Information

Emergency Contact's Name*

First Last

What is the Emergency Contact's Relationship to You?*

Emergency Contact's Primary Phone*

Emergency Contact's Secondary Phone*

General Authorization

PLEASE READ CAREFULLY, AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.  I affirm that I have legal custody of the minor children/persons indicated below. Should an emergency occur during the duration of BREAKAWAY, I give my authorization and consent for the BREAKAWAY staff to authorize necessary medical care for this child. Such medical treatment shall be provided upon the advice of and supervision by any physician, surgeon, or other medical practitioner licensed to practice in the United States.  I give my consent that information on this application may be communicated to BREAKAWAY staff and Crew Members for the purpose of being equipped to provide the best care and assistance possible to my family.  Permission is given only to Lift Disability Network to use photographs (individual or group) and/or multi-media images and recordings in the best interest of Lift Disability Network. I understand that photographs/video/images I take at any BREAKAWAY/Lift Disability Network function are for my personal use only. Personal internet use of any video/media should be approached with caution with regard to misrepresentation.  I release Lift Disability Network, its staff, and Crew Members, and the BREAKAWAY facility from all actions, damages, or personal injuries which may occur to me or a member of my family. I understand in the event of a minor injury I, or a member of my family, may receive first aid treatment. I will be informed as soon as possible of any injury or condition of one of my family members and will be responsible thereafter for their care. In the event of an emergency, injury, or illness, emergency medical services and I will decide the best course of action. If the BREAKAWAY staff is unable to reach me, I authorize them to take whatever action is necessary for the safety and health of my family members.  I understand that participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,  I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,  I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.  I realize that tobacco, alcohol, and illegal drugs are NOT ALLOWED.

Signature*

Type Full Name

Signature of Parent of Guardian*

Type Full Name

Captcha

2023 Breakaway Adult Family Member Application

Your cost for this incredible week is $450.00.

Family Information

Family Member Contact Information

Emergency Contact Information

Family Member General Information

Family Member Medical History

Health Insurance Company

Primary Doctor

Family Member Abilitites

General Authorization