2019 MO Breakaway Individual Camper Application

Individual Camper General Information
Name*
First Middle Last
Preferred Name*
First
for Name Tag
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Work Phone
Cell Phone
Email*
Enter Email Confirm Email
I Reside at:*
- Own Home/Apt.
- Family Home
- Residential Facility
Name of Residence
I am my own Guardian*
- Yes
- No
Name of Gaurdian
Relationship to Guardian
Guardian Phone
Emergency Contact Information
Emergency Contact*
First Last
Relationship*
Emergency Contact Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact Phone*

General Authorization
PLEASE READ CAREFULLY, AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I hereby give permission as legal guardian, for the individual named above to attend Breakaway. To the best of my knowledge, the information on the Ability Evaluation and the Medical History Report is correct and this individual has permission to engage in all activities, except as noted by myself and/or the Health Care Professional. I further understand that Lift Disability Network reserves the right to reject any applicant whose needs cannot be met by our staff or Crew Members. I understand that due to some state laws, ALL medications and/or vitamins brought to Breakaway MUST be in their original prescription containers, clearly labeled with the recipient, medication, dosage, frequency, route, prescribing physician, RX#, pharmacy info, expiration date and not in pre-poured containers. Pharmacy bubble packs are preferred. Pre-poured daily containers are not acceptable. I agree to relieve all Lift Disability Network personnel and its corporate entities from liability in connection with Breakaway. If I cannot be reached in an emergency, I hereby give permission to the Health Care Professional selected by the Breakaway staff to hospitalize, secure proper treatment, and to order injection, anesthesia, surgery or other medical care for this individual. I will assume all financial responsibility for any medical treatment required. If applicant displays inappropriate behavior which causes dismissal, legal guardian, or residence assumes immediate responsibility for transportation and its cost to return this individual home, and no refunds will be given. I agree not to send this individual if exposed to a contagious disease within three weeks of the event, and I will notify Breakaway if this individual must cancel. Permission is given only to Breakaway and its corporate entities to use photographs (individual or group) and/or multi-media images and recordings in the best interest of said organization. I understand pictures I take at Breakaway are for personal use only. Personal internet use of any video/media should be approached with caution with regard to misrepresentation. No one will be denied attendance to a Breakaway because of religion, creed, national origin, sex, age, or disability. I realize that tobacco, alcohol, and illegal drugs are NOT ALLOWED.
Signature of Guardian (or Applicant if own gaurdian)*
Type Full Name
Captcha

Your cost for this incredible week is just $300.00.

Step 1 of 5 - General Information

Individual Camper General Information

Emergency Contact Information

Individual Camper General Information

Individual Camper Medical History

Individual Camper Abilitites

General Authorization