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2020 Silver Birch Fall Retreat*What is Silver Birch? It’s our annual Fall middle school weekendretreat at Silver Birch Ranch near White Lake, WI. It’s a great chancefor kids to break away from their routines and unwind with all kinds ofindoor and outdoor activities (see: silverbirchranch.org/recreation). Butmore importantly, they’ll have a chance to work through some largegroup lessons and some small group discussions that will challengethem in their walk with God. And these retreats are always greatopportunities for them to build strong relationships with one another!*Open to all students grades 6-8*October 30th – November 1st, 2020*Cost: 120-Talk to Jon or a small group leader if you’d like to go but the costwill be a challenge.*Checks made out to: Faith Reformed Church*Registration deadline: Sunday, October 25th-Turn in forms and payment in the collection boxes at Connect orCore, or place them in the box on Jon’s door.*Bus departs from Faith Reformed (243 S. 4th St.) onFriday, October 30th at 5:30PM.-Bring your luggage when you drop off your child on the 30th.-Bring your COVID screening form on the 30th (see pg. 2 for details).-We will not stop for dinner on Friday night, so students should eatbefore they are dropped off.-We will stop at Culver’s on the way home, so bring .*We will return home to Faith Reformed approximately3:30PM on Sunday, November 1st.
2020 Silver Birch Fall RetreatItems to Bring:Weather-appropriate clothes (that may be used for outdoor activities)Sleeping bag & PillowToiletry items (toothbrush & paste, soap, shampoo, etc.)TowelBible (if you have one), notebook & penMoney for snacks/souvenirs/Culver’sOptional: snacks; cards or non-electronic games for free timeCOVID Screening:The SBR COVID Screening/Waiver form is on pages 5-6. You will need to begin screening for symptomson Saturday, October 24th. Please fill out this form and bring it along on October 30th when we meet fordeparture. (Note: if your son/daughter signs up for the trip and is unable to attend due to sickness, you willreceive a full refund.)Dietary Needs:Silver Birch can make gluten-free or dairy-free meal accommodations. If needed, please check theappropriate box on the permission form.Phone Policy:Please leave cell phones at home; parent-requested cell phones used only for maintaining communicationwith a parent are acceptable. A list of contact numbers of several chaperones will be provided to parents.Names, Numbers & Places:Silver Birch Ranch (near White Lake, WI)Website: www.silverbirchranch.orgPhone: (715) 484-2742Emergency Telephone Number:Jon’s Cell phone: (920) 447-2335
2020 MS Silver Birch Fall RetreatPermission / Medical Release FormI, (parent/guardian) , give my son or daughterpermission to go on the 2020 Silver Birch Fall Retreat (for grades 6-8) at Silver Birch Ranch. I understandthe retreat departs Friday night, October 30th and returns on Sunday, November 1st 2020. I understand thetotal cost of the trip is 120 which includes meals, lodging, and transportation to and from Silver BirchRanch. (Please make your check out to Faith Reformed Church). Registrants will need to bring money forany snacks or souvenirs they wish to purchase on the trip, and also for Culver’s on the way home. Pleaseturn in your money & permission slip at the specified locations by Sunday, October 25th, 2020.I understand that the event will take place at Silver Birch Ranch near White Lake, WI. I understand thatwhile there my child may be exposed to/participate in all kinds of Fall outdoor activities, including but notlimited to: Horseback riding, paintball, basketball, sports & field games, swimming, canoeing/boating,hiking, zip-lining, rock-wall climbing, worship and spiritual growth opportunities. Should an accident orinjury of any kind occur while participating, I release Faith Reformed Church, Calvary OrthodoxPresbyterian Church, and First Evangelical Presbyterian Church, along with their pastors, boards, directors,leaders, sponsors and other adults representing the church on the trip from any responsibility or liability forthe accident or injury and from any claim for damages from the accident or injury. In the event thatemergency medical treatment is required, I give my permission to the adult leaders to obtain necessarymedical treatment for me.Registration InformationName: Birth Date:Address: Cell #Parent Cell (name/number)Emergency Contact (name/number)Doctor: (name/number)Allergies: Dietary accommodations:DairyGlutenCurrent Medications (to be handed to leaders at the start of the trip):Significant Medical History/Special needs:Insurance Carrier:Group # Policy #I have carefully read and understood this entire document before signing it.Participant’s signature:Date:Parent/Guardian signature: Date:
Retreater/Volunteer Name: Retreat Dates:Pre-Retreat Health ScreeningYou must bring this Health Screening and COVID-19 Waiver Form to Check-In at SBR,the SBR Bus/Van, or Youth Group Check-In or you will not be able to attend the retreat.Dear Retreater,In an effort to minimize illness at camp we ask that you check on the health of all retreaters/volunteersdaily beginning 7 days prior to camp. The best retreat sessions start with healthy retreaters/volunteersand this begins at home.Please indicate if you/your retreater has any of the following symptoms prior to your retreatand record a temperature daily. If any temperature or symptoms are present, please havethe retreater/volunteer evaluated by a licensed provider and contact camp for furtherguidance.Symptoms: Cough Shortness of breath ordifficulty breathing Fever Chills Muscle Pain Sore throat New loss of taste or smell Nausea Vomiting DiarrheaPlease initialNo one in our household has been sick in the 7 days priorto your retreat. InitialNote: A retreater with a temp of 100.4 or above will not be able to attend the retreat.Start date oftemperature/symptomscreening:Day:765432day1 firstof campTemp/sympOur signatures indicate that we completed this health screening daily for 7 days prior to theretreat and to the best of our ability. We understand that arriving to camp healthy is vital to ahealthy retreat for all retreaters/volunteers.Parent Signature (If child under 18): Date:Retreater/Volunteer Signature: Date:Page 1 of 2
COVID-19WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENTIn consideration for BEING ON PREMISES at SILVER BIRCH RANCH, NICOLET BIBLE INSTITUTE ANDWOLF RIVER REFUGE (hereinafter called “SBR”), I, on behalf of myself and any minor child/children forwhom I have the capacity to contract, hereby acknowledge and agree to the following:1. I understand the hazards of the novel coronavirus (“COVID-19”) and am familiar with theCenters for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19 and SBR’sCOVID-19 protocols. I acknowledge and understand that the circumstances regarding COVID-19are changing from day to day, and that accordingly, the CDC guidelines are regularly modiYiedand updated. I accept full responsibility for familiarizing myself with the most recent updates atthe CDC and SBR websites.2. Notwithstanding the risks associated with COVID-19, which I readily acknowledge, I herebywillingly choose to participate in SBR activities and abide by SBR’s COVID19 preventionprocedures, which include the following:a. I understand that if SBR determines that a camper/volunteer/staff member needs to gohome, I as the parent am responsible to pick up that person within 12-18 hours of beingnotiYied.b. I understand that camp will do its best to offer as many activities as possible, but thatprograms and procedures will look different from past years past due to COVID19precautions.3. I acknowledge and fully assume the risk of illness or death related to COVID-19 arising from mybeing on the premises and participating in the SBR activities and hereby RELEASE, WAIVE,DISCHARGE, AND COVENANT NOT TO SUE (on behalf of myself and any minor children fromwhom I have the capacity to contract) SBR (Silver Birch Ranch Inc), its afYiliated companies,owners, ofYicers, directors, agents, and employees, and release SBR from any liability related toCOVID-19 which might occur as a result my being on the premises and participating in the SBRactivities.4. I shall indemnify, defend, and hold harmless SBR from and against any and all claims, demands,suits, judgments, losses or expenses of any nature whatsoever (including, without limitation,attorneys’ fees, costs, and disbursements, whether of in-house or outside counsel, and whetheror not an action is brought, on appeal or otherwise), arising from or out of, or relating to, directlyor indirectly, the infection of COVID-19 or any other illness or injury.5. It is my express intent that this Waiver and Hold Harmless Agreement shall bind any assigns andrepresentatives, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOTTO SUE the above-named SBR companies. This Agreement and the provisions contained hereinshall be construed, interpreted and controlled according to the laws of the State of Wisconsin.6. I HEREBY KNOWINGLY AND VOLUNTARILY WAIVE ANY RIGHT TO A JURY TRIAL OF ANYDISPUTE ARISING IN CONNECTION WITH THIS AGREEMENT. I ACKNOWLEDGE THAT THISWAIVER WAS EXPRESSLY NEGOTIATED AND IS A MATERIAL INDUCEMENT THEPERMISSION GRANTED BY RELEASEES TO BE ON PREMISES AND PARTICIPATE IN THEACTIVITIES.IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoingWaiver of Liability and Hold Harmless Agreement, understand it, and sign it voluntarily as myown free act and deed; no oral representations, statements, or inducements, apart from theforegoing written agreement, have been made; I am at least eighteen (18) years of age and fullycompetent; and I execute this Agreement for full, adequate, and complete consideration, fullyintending to be bound by same.IN WITNESS WHEREOF, I have signed this Waiver and Agreement this the day of , 20 .SIGNATURE:NAME:NAMES OF MINOR CHILD(REN):Page 2 of 2
In consideration for BEING ON PREMISES at SILVER BIRCH RANCH, NICOLET BIBLE INSTITUTE AND WOLF RIVER REFUGE (hereinafter called “SBR”), I, on behalf of myself and any minor child/children for whom I have the capacity to contract, hereby acknowledge and agree to the following: 1. I under
