November 17-19, 2017

Size: px
Start display at page:

Download "November 17-19, 2017"

Transcription

1 NE District High School Youth Gathering 9th-12th grade vember 17-19, 2017 LaVista Conference Center Omaha, Nebraska $200/person Registration Deadline: October 1st (Scholarships available) Late registration fee: $35 How to register: Return completed forms (listed below) and a $135 non-refundable deposit to Julie Keeley. Checks may be out to Peace Lutheran Church with HS NE-YG in the memo line. Drop-off and Pick-up at Peace Lutheran Church. Leave on Fri., v. 17 at 3:30pm. Return on Sun., v. 19 at 3:30pm. Forms Checklist: Emergency Information Form (For NE district) *Participation Agreement and Liability Waiver (For Peace Lutheran) *Medical Information Form (For Peace Lutheran) *Behavior Expectations Form * These forms only need to be turned in once per school year for all events. For more information, contact Julie Keeley at or jkeeley@peacegi.org. Sponsored by the Nebraska District LCMS

2 EMERGENCY INFORMATION FORM *Make copies of this form for EACH participant. Once completed, please make two copies of this information (Send original with registration materials; keep one with the Family Group Leader; and keep one with the participant) Name: (Last) (First) (Middle Initial) Mailing Address: (Street) (City) (State) (Zip) Male: Female: Age: Date of Birth: (MM/DD/YEAR) Parent s Name(s) (if under age 21): Parent s Phone - Home ( ) Cell1( ) Cell 2( ) HEALTH INFORMATION: To be completed by ALL Participants Please explain special diet and health arrangement needs: General: Do you have: (If yes, please explain) Allergies? Heart? Other? Are you subject to: (If yes, please explain) Fainting? Sleep Walking? Upset Stomach? Other? Do you have reaction to (If yes, please explain). Bee Sting? Penicillin? Other Drugs? Poison Ivy, Oak, Sumac? Other? Have you had any serious illness or surgery within the past ten years? Do you have any condition that would prevent you from participating in any activities? Please list: Are you diabetic? Do you have any sight or hearing impairment? Do you wear contact lenses? Date of last Tetanus shot: Please list ANYTHING else the leaders should know to help avoid or deal with any situation that might arise: INSURANCE INFORMATION: MUST BE INCLUDED Health Insurance Co.: Policy.: Name of policy holder: Name of another person to contact: Friend/Relative Address: (Street) (City) (State) (Zip) Telephone: Home( ) Work( ) Family Doctor s Name: Work Phone ( ) Family Dentist s Name: Work Phone ( ) Do any pre-certification, notification, or other requirements exist with respect to the health insurance participant? If so, specify COMPLETE OTHER SIDE OF PAGE

3 AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE PERMISSION TO ATTEND FORM For participants under 21 years old: I/We, the undersigned parent(s) and/or natural guardian(s) of, a minor, do hereby authorize my/our child s youth leader or an agent of the Nebraska District of The Lutheran Church Missouri Synod to arrange for such medical, dental, or hospital treatment as deemed advisable for the health and well-being of the above named minor during the Nebraska District Jr. High Gathering. I/We understand that an attempt will be made to notify the parent(s)/guardian(s) first. However, if parent(s)/guardian(s) are not available, or if the need for medical attention is immediate, the above authorization will be used. I/We understand that this authorization is given in advance of the occurrence of any condition or situation that would necessitate any such medical, surgical, or dental care, but is given to provide authority to obtain such care if it should be required. I/We give permission for my/our child to attend and fully participate in the Nebraska District Jr. High Gathering (please refer to the activities listed on the enclosed sheet). I/We give the Nebraska District the right to use the image and comments of my/our child/ward for publicity and news release purposes. I understand I will not be given any creative control over the finished use of the image. I understand that neither I, nor my minor child/ward are or will be compensated for this participation. I/We fully understand the consequences of the foregoing statements and sign this EMERGENCY INFORMATION/AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE/ PERMISSION TO ATTEND FORM knowingly, freely, and willingly. Signature: (parent/guardian signature) Signature: (parent/guardian signature) Witness: For participants over 21 years old: I certify that I am at least 21 years old. I hereby agree to serve as an adult leader and to participate fully in the Nebraska District Jr. High Gathering. I will supervise and care for all members of my Family Group throughout the Gathering experience. I grant the Nebraska District permission to use still or video images of my person and my comments for publicity and news release purposes. I understand I will not be given any creative control over the finished use of the image. I understand I will not be compensated for this participation. Signature: (Family Group Adult Leader signature)

4 High School Youth Ministry Program Participation Agreement YOUTH PARTICIPANT INFORMATION Effective Dates: September 1, 2017 August 31, 2018 Name of participant: DOB: Male Female Nickname: School: Grade entering in Fall 2017: 9 th 10 th 11 th 12 th Graduated Youth Primary Address: Youth Youth Home Phone: Youth Cell Phone: PARENT/ GUARDIAN INFORMATION Name(s): (s): List all phone numbers where the parent(s)/guardian(s) can be reached (type: i.e. home, cell) EMERGENCY CONTACT Name # Relation? Name # Relation? PARENTAL CONSENT: The undersigned does hereby give permission for my child, (child s name), to attend and participate in any Peace Lutheran Church High School Youth Ministry Program activities including, but not limited to, events such as Sunday School, youth group nights, trips, lock ins, and retreats during the period of 9/1/2017 8/31/2018. LIABILITY RELEASE: In consideration of Peace Lutheran Church allowing the Participant to participate in the High School Youth Ministry Program (Sunday School, Youth Group Nights, lock ins, retreats, trips, and other related events), I, the undersigned, do hereby release, forever discharge and agree to hold harmless Peace Lutheran Church, its pastors, directors, employees, volunteers and teachers (collectively herein the Church ) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in Youth Ministry Program activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto. EARLY HOME POLICY: Should it be necessary for my child to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Peace Lutheran Church. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. Parent s/guardian s Printed Name: Parent s/guardian s Signature: If the participating youth is 19 years of age or over: Youth s Printed Name: Youth s Signature: 1 of 1

5 YOUTH PARTICIPANT (Please Print) High School Ministry Program Medical Release Form Effective Dates: September 1, 2017 August 31, 2018 Youth Full Name DOB: PARENT/GUARDIAN Parent/Guardian Name(s): PRIMARY CARE PHYSICIAN Name: Name of practice: Phone(s): INSURANCE INFORMATION Medical Insurance Company: Phone: Policy Holder s Name: Policy/Group ID#: MEDICATION: List all medications the youth will take during any youth ministry program events. This includes any prescription, non prescription medications, herbal supplements and vitamins. Any youth participant in a Youth Ministry program is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non prescription medication and will be sent home at the parent/guardian s expense if they do. Medication Name Dose Treatment for Dispensing instructions Example: Zyrtec 5mg Seasonal allergies Take one pill daily in the morning with food OVER THE COUNTER MEDICATION PERMISSION: Do you give permission for your child/youth to be given over the counter medication as needed and as directed on the label, to treat nonemergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry program event? NO. Contact me or get medical help if my child has any emergency medical concerns. Parent signature: YES. I give permission for an adult leader to give my child approved emergency prescription medications as directed on an as needed basis to treat emergency medical conditions. Parent Signature: MEDICAL TREATMENT PERMISSION AND AUTHORIZATION: I understand that my or my minor child s/ward s presence at and participation in Peace Lutheran Church s program or activity presents varying degrees of certain risks some of which are unknown which may arise from a condition of the premises at which the program or activity is held; from the action of any person in connection with the preparation for, supervision of or conduct of any activity whether planned or unplanned; or from foreseeable or unforeseen elements or factors. I hereby give informed and expressed consent for this individual to take part in all activities under supervision, and agree that the church or church personnel will not be held responsible for accidents arising there from. I authorize the designated church staff to provide appropriate treatment to this individual for injuries and/or illness. This includes, but is not limited to, following Peace Lutheran Church s medical procedures and protocols, following poison control recommendations, administering prescription medications as noted above, administering over the counter medications as approved above, transportation to clinic or hospital care, and following directions from the medical director. I understand that the information on this form may be released to the appropriate medical personnel in case of emergency. I agree to pay any cost for medical care in the event of an emergency, even if I do not have health insurance coverage or not all costs are covered by insurance. I also understand that failure to disclose medical or emotional problems in advance may lead to serious consequences while at a church activity/program. Lastly, I verify that everything contained on this form is complete and accurate, to the best of my knowledge. Parent s/guardian s Printed Name: Parent s/guardian s Signature: If the participant is 19 years of age or over: Participant s Printed Name: Participant s Signature: 1 of 2

6 HEALTH HISTORY Emergency Medical Information Form If : If : If : If : If : Sight or Hearing Impairment Recurrent Headaches Heart Disease or Problems Diabetes ADD or ADHD Contacts Epilepsy or Convulsions Ear, se, or Throat trouble Anxiety, or Depression Motion Sickness Hearing Aids Asthma Stomach or Intestine trouble Dizzy Spells or Fainting Sleepwalking Disease or injury to joints or back Comments, other issues, physical limitations and/or list surgeries ALLERGIES Type of Allergy Describe/Specify Allergen Severity of Reaction (please check one) Describe Reaction Food Medication Environmental (animal, plant, insect, etc.) Other Blood Type (if known): Date of last tetanus shot (or estimated date): SWIMMING ABILITY: n swimmer Beginner Advanced MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary. 1. List any other medical conditions the participant may have that are not listed in the above table. 2. Does the participant have any condition that would prevent him/her from participating in any particular activity? Please list. 3. Are any drugs ineffective in treatment? 4. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know. 2 of 2

Community Life Center

Community Life Center Community Life Center- 2018-2019 Page 2 of 6 MEGA SPORTS CAMP- Waiver & Release Forms Effective Dates: January 1, 2018 January 1, 2019 CHILD S INFORMATION Name Grade Age DOB Male/Female Nickname School:

More information

Emergency Contact other than Parent or Guardian (Required): Name: Relationship:

Emergency Contact other than Parent or Guardian (Required): Name: Relationship: 1 The Episcopal Diocese of North Carolina 20 HUGS Camp Special Needs CAMPER Registration Download form. Complete ALL information on computer then print and sign. This form may be saved on your computer.

More information

August, GA 13. June 10-15

August, GA 13. June 10-15 August, GA 13 June 10-15 Jan. 16, 2013 Dear parents and students 6 th -12 th grade, Our excitement is growing for our missions opportunity this summer for all middle school and high school students. We

More information

RETURNING STUDENT INFORMATION UPDATE

RETURNING STUDENT INFORMATION UPDATE ST. FRANCIS CATHOLIC SCHOOL Student Information Date: RETURNING STUDENT INFORMATION UPDATE Student Name Last First Middle I Nickname Birth Date Gender Grade Entering Birth Country Birth City Birth State

More information

Michael Jordan. Questions? Please contact: Director of Youth Ministry. Phone: x230

Michael Jordan. Questions? Please contact: Director of Youth Ministry. Phone: x230 What: Youth will travel to Idaho to partner with Idaho Servant Adventures, a ministry of Lutherhaven. During this servant-leadership camp, we will work alongside other youth groups repairing and transforming

More information

2018 SUMMER DAY CAMP ENROLLMENT PACKET

2018 SUMMER DAY CAMP ENROLLMENT PACKET 2018 SUMMER DAY CAMP ENROLLMENT PACKET Enrollment : Child s Full Name: Mother s Name: AGE: Birth : Home Father s Name: Gender: (Please circle) M F Mother s Father s Mother s Home Father s Home Employer:

More information

Building Relationships with God, Youth and our Neighbor

Building Relationships with God, Youth and our Neighbor What: Who: Recognize that our neighbor is someone as worthy of God s love as I 2014 Theme Being Jesus Rejoicing and Sharing God s Love with the World John 3:16-18 / 2 Corinthians 13:11-13 Mission Statement

More information

U.S. Martial Arts Academy SUMMER CAMP 2015

U.S. Martial Arts Academy SUMMER CAMP 2015 U.S. Martial Arts Academy SUMMER CAMP 2015 3430 Oak Road Vineland, NJ 08361 Hours of operation 7:30am-5:30pm (Monday-Friday) Dates of Operation: Monday June 22nd thru Friday August 28th CLOSED WEEK OF

More information

TOPS Piano and Creative Writing Camp Registration Form Summer 2018

TOPS Piano and Creative Writing Camp Registration Form Summer 2018 TOPS Piano and Creative Writing Camp Registration Form Summer 2018 Returning Camper New Camper Camper s Name Email(s) Address City Zip code Home phone Work phone(s) Cell phone(s) Parent/Guardian name Please

More information

4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm

4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm 4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm Please type or print using black ink. Scholarship covers travel

More information

Superintendent s Regulation 4400-R Exhibit 1

Superintendent s Regulation 4400-R Exhibit 1 Superintendent s Regulation 4400-R Exhibit 1 School Field Trip Planning Form Instructions All information on this form must be completed before presenting the form for approval to the Principal, School

More information

**** Medical Information/ Emergency Contacts/ Insurance/ Consent ****

**** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Arrival Departure Certification Level: **** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Camper s Name: Birthdate: Age: Parent/Legal Guardian/Adult Leader Name: Day Time Phone: Evening

More information

4-H Countywide Youth Lock-In Friend Registration Form

4-H Countywide Youth Lock-In Friend Registration Form 4-H Countywide Youth Lock-In Friend Registration Form Who?- Youth in Grades 4 th -8 th Where?- Kettle Moraine YMCA 1111 West Washington Street, West Bend When?- 8:00pm Saturday December 2 nd until 6:00am

More information

Kennedy King College-Minority Science and Engineering Improvement Program 2013

Kennedy King College-Minority Science and Engineering Improvement Program 2013 Dear Student & Parent/Guardian: This is the Application Packet for the Minority Science and Engineering Improvement Program at Kennedy King College. All documents within this packet must be completed and

More information

Attached you will find all necessary forms for registration. These forms may also be accessed at the link below:

Attached you will find all necessary forms for registration. These forms may also be accessed at the link below: Dr. Jillian Bohlen Animal and Dairy Science Department 425 Rhodes Center for Animal and Dairy Science Phone: 706-542-9108 E-mail: jfain@uga.edu April 26 th, 2018 4-H Agents, FFA Advisors, Youth Leaders

More information

August 4 -August 7, 2016

August 4 -August 7, 2016 Minnesota District Royal Rangers DISCOVERY LEADERSHIP TRAINING CAMP THE WOODS AT LAKE PLACID PILLAGER, MN August 4 -August 7, 2016 PURPOSE OF THIS CAMP Discovery Training Camp will provide boys with training

More information

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission: Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment

More information

6 th GRADE CAMP 2016 AUGUST 1 - AUGUST 5, 2016 REGISTRATION/PAYMENT INFORMATION

6 th GRADE CAMP 2016 AUGUST 1 - AUGUST 5, 2016 REGISTRATION/PAYMENT INFORMATION 6 th GRADE CAMP 2016 AUGUST 1 - AUGUST 5, 2016 REGISTRATION/PAYMENT INFORMATION 6 th Grade Camp is for students entering the 6 th grade during the Fall of 2016. I will be attending with (circle one): Woodway

More information

PROGRAM TO COMPLETE YOUR REGISTRATION PLEASE KEEP A COPY OF COMPLETED FORMS FOR YOUR RECORDS

PROGRAM TO COMPLETE YOUR REGISTRATION PLEASE KEEP A COPY OF COMPLETED FORMS FOR YOUR RECORDS GENESEE COUNTY YMCA GENESEO SUMMER REC PROGRAM 2018 PARTICIPANT FORMS MONDAY JULY 2ND FRIDAY AUGUST 10TH 9AM-1PM COMPLETE YOUR REGISTRATION REGISTRATION: MAIL COMPLETED FORMS AND PAYMENT 209 E MAIN ST.

More information

St. Joseph Parish Youth Ministry Registration 2018/19

St. Joseph Parish Youth Ministry Registration 2018/19 St. Joseph Parish Youth Ministry Registration 2018/19 Please take a moment to register for this year s Youth Ministry program at St. Joseph, Colbert. St. Joseph Parish s Youth Ministry programs are open

More information

After School Program ABBOT DOWNING SCHOOL BEAVER MEADOW SCHOOL

After School Program ABBOT DOWNING SCHOOL BEAVER MEADOW SCHOOL @ Y 21C Y@21C is a partnership between the 21st Century Community Learning Centers and the Concord Family YMCA. PLEASE NOTE: registration must be confirmed by the YMCA before your child can attend program.

More information

4-H Memorial Camp. Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information

4-H Memorial Camp. Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information 4-H Memorial Camp 2018 Summer Camp Registration Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information Camper s First Name Male Female Camper

More information

4-H HEALTHY LIVING RETREAT OCTOBER 13 TH -15 TH. Learn about careers & other opportunities in the healthy living field!

4-H HEALTHY LIVING RETREAT OCTOBER 13 TH -15 TH. Learn about careers & other opportunities in the healthy living field! Learn about careers & other opportunities in the healthy living field! Attend workshops on trending topics in Healthy Living! OCTOBER 13 TH -15 TH 4-H HEALTHY LIVING Take the 500 Mile Challenge, and participate

More information

NOTE: WE REQUEST THAT PARISHES AND SCHOOLS DO NOT USE THE RALLY AS A SUBSTITUTE FOR A CONFIRMATION RETREAT.

NOTE: WE REQUEST THAT PARISHES AND SCHOOLS DO NOT USE THE RALLY AS A SUBSTITUTE FOR A CONFIRMATION RETREAT. M E M O TO: FROM: CYMs, DREs and Middle School/Jr. High Principals Clare Kolenda, Middle School Youth Rally Coordinator Brian Flynn, Office of Youth Ministry DATE: January, 2018 RE: Middle School Youth

More information

Kids for a Cure Club Day Camp June 18-21, 2018

Kids for a Cure Club Day Camp June 18-21, 2018 1) Requirements: Age 13 or 14 Kids for a Cure Club Day Camp June 18-21, 2018 Junior Counselor Requirements and Application Check List Teacher s written recommendation (if new to the KFCC camp) Documentation

More information

2016 Old Sacramento History Camp Registration Guide

2016 Old Sacramento History Camp Registration Guide General Camp Information: 2016 Old Sacramento History Camp Registration Guide Old Sacramento History Camp is held in Old Sacramento. It is located in the Sacramento History Museum s Living History Center,

More information

Counselor Application 2018 July 9 th 13 th

Counselor Application 2018 July 9 th 13 th Counselor Application 2018 July 9 th 13 th Name Address City State & Zip Home Phone Cell Phone E-mail address Male Female Birth Date (mm/dd/yy) Age (at camp) Emergency Contact Name Phone Relation to Camper

More information

Student T-shirt size is: Small Medium Large XLarge 2XLarge 3XLarge (Circle one)

Student T-shirt size is: Small Medium Large XLarge 2XLarge 3XLarge (Circle one) Participant Permission Form/ Release Waiver Form My child,, has my permission to attend. I understand this celebration is offered to all graduates who have signed and maintained both the Project Grad Participant

More information

2018 Counselor College

2018 Counselor College OHIO STATE UNIVERSITY EXTENSION 2018 Counselor College Canter s Cave 4-H Camp, Jackson, Ohio March 24 th @ 1:00 p.m. - March 25 th @ 10:30 a.m. Counselor College is open to any teen, 14-18 years of age,

More information

*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE*

*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE* WASHINGTON ACADEMY STUDENT HEALTH INFORMATION PACKET SCHOOL NURSE: PHONE: 973-239-6555 Ext: 204 FAX: 973-239-6335 *A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR

More information

Diane Kulas, LSW. Dear Parent/Guardian,

Diane Kulas, LSW. Dear Parent/Guardian, Dear Parent/Guardian, Thank you for your interest in Camp Chimaqua, an overnight bereavement camp, through Hospice & Community Care s Pathways Center for Grief & Loss. The camp will be held on June 9-11,

More information

Student Summer Travel Application Iceland Parts A & B: Student Information & Emergency Contacts

Student Summer Travel Application Iceland Parts A & B: Student Information & Emergency Contacts Parts A & B: Student Information & Emergency Contacts 1. Student Name 2. I.D. Number Current Year in School 3. Email 4. Date of Birth 5. Names of parents/guardians 6. Address City, State, Zip 7. Home Telephone

More information

Registration Form Needs completed, signed with Notary, and a copy of insurance card included (if applicable).

Registration Form Needs completed, signed with Notary, and a copy of insurance card included (if applicable). CAMPER PACKET INCLUDES: Registration Form Needs completed, signed with Notary, and a copy of insurance card included (if applicable). Code of Conduct signed by students and parents with dates. Suggested

More information

University of South Alabama

University of South Alabama 2014 Concert Honor Wind Ensemble Schedule of Events Friday, December 5, 2014 o 3:00 PM- 4:00PM - Registration Open (Lobby of the Laidlaw Performing Arts Center) Accepted students will be assigned a part

More information

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY 2016-17 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 08.01.16) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group

More information

Watermarks MS/HS Camp Information

Watermarks MS/HS Camp Information Watermarks MS/HS Camp Information When: Friday, November 13 - Sunday, November 15 Where: Watermarks Camp in Scottsville, VA (just south of Charlottesville) Cost: $110 Register by November 2. We will leave

More information

2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults

2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults 2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults Complete this form in ink answering all questions. Please print legibly The parent/guardian and camper both must sign this

More information

Information Packet: Never the Same Camp

Information Packet: Never the Same Camp Information Packet: Never the Same Camp July 24-28, 2016 Important Dates: - Early Registration Deadline: May 8, 2016 - Transportation Fee/New Life Medical Form Due: July 10, 2016 - Late Registration Deadline:

More information

Frontiersmen Camping Fellowship

Frontiersmen Camping Fellowship Explorer Territory North Star Chapter Frontiersmen Camping Fellowship Application for Membership (Please Print Legibly) Print Name: Phone: (First) (Middle) (Last) Address: E-Mail: Tee-Shirt Size Age: Birthday:

More information

ST. CHARLES BORROMEO FOUNTAIN OF YOUTH YOUTH MINISTRY PROGRAM

ST. CHARLES BORROMEO FOUNTAIN OF YOUTH YOUTH MINISTRY PROGRAM YOUTH MINISTRY PROGRAM The St. Charles Borromeo Fountain of Youth is a unique Youth Ministry Program open to all young people in St. Charles Borromeo Church Parish in grades 5 12. Junior High Program is

More information

(8-12 years old) Sponsored by Perry Hall Baptist Church

(8-12 years old) Sponsored by Perry Hall Baptist Church (8-12 years old) Sponsored by Perry Hall Baptist Church Call or e-mail us to request a Registration Form and a Health Form. Forms must be returned with full payment. Space is limited Register soon!! Wo-Me-To

More information

We ll meet in the Youth Room at 2:30 p.m. and we ll return by 6:30 p.m. (depending on traffic)! For students in grades 7-12.

We ll meet in the Youth Room at 2:30 p.m. and we ll return by 6:30 p.m. (depending on traffic)! For students in grades 7-12. For I was hungry and your gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me. Matthew 25:35 The Dallas Life Foundation is a Christian based homeless shelter

More information

VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM

VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM 1 VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM When: Residential camp: June 24 (Sunday)-June 29 (Friday), 2018 Commuters: June 25 (Monday)-June 29, 2018 In order to get personal

More information

2018 RA Camp Discount Application

2018 RA Camp Discount Application 2018 RA Camp Discount Application Thank you for choosing Reston Association and placing your child(ren) in our care. The intent of the RA Camp Scholarship Program is to provide financial assistance to

More information

4-H Camp Tech. June Nationwide & Ohio Farm Bureau 4-H Center on

4-H Camp Tech. June Nationwide & Ohio Farm Bureau 4-H Center on 4-H Camp Tech June 13-14-15 Nationwide & Ohio Farm Bureau 4-H Center on the OSU campus You ll learn about science, technology, engineering and math through challenges and activities, including: Write code

More information

Camper Health History Form

Camper Health History Form Camper Health History Form Dates will attend camp: from to Camper name: (first) (middle) (last) Male Female Birth Date Age on arrival at camp: Camper Home Address: Street Address City State Zip Code Parent/guardian

More information

Huntington University Nursing Career Academy Application Process Summer 2015

Huntington University Nursing Career Academy Application Process Summer 2015 Application Process Eligibility Requirements: applicants must be in 10 th, 11 th, or 12 th grade during the 2014-2015 academic school year and be interested in exploring a career in nursing. Program cost:

More information

Parma High School Washington, DC Trip 2018

Parma High School Washington, DC Trip 2018 Parma High School Washington, DC Trip 2018 Dear Parents: Please find the attached Parents Approval Form Educational Trips Overnight / Out-of-State / Out-of-the-Country. Parents are asked to neatly print

More information

Glastonbury YMCA 29 Welles Street, Glastonbury CT Dear YMCA Family,

Glastonbury YMCA 29 Welles Street, Glastonbury CT Dear YMCA Family, s Dear YMCA Family, Thank you for choosing the Glastonbury Family YMCA Preschool for your early childhood child care needs. We are excited to welcome you and your family to our program! The Y s focus is

More information

Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens.

Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens. Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens. Who do we play? Other Youth Ministries from the Dallas Diocese When do we play?

More information

Sara Merrill, LSW & Elaine Ostrum, LCSW. Dear Parent/Guardian,

Sara Merrill, LSW & Elaine Ostrum, LCSW. Dear Parent/Guardian, Dear Parent/Guardian, Thank you for your interest in Camp Mend A Heart, a day bereavement camp sponsored by the Pathways Center for Grief & Loss. Our goal is to help families learn how to grieve together

More information

STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016

STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 The Clinic The Howard School 1192 Foster Street, NW Atlanta, Georgia 30318 Please complete this form and return with the other enrollment forms. Student

More information

2017 Summer Camp Registration

2017 Summer Camp Registration 1515 N. Galloway Avenue Mesquite, Texas 75150 972.216.6260 www.cityofmesquite.com 2017 Summer Camp Registration Please select which camp your child(ren) will be attending BLAST Camp Sports Camp Teen Camp

More information

KANSAS PACKET INSTRUCTIONS

KANSAS PACKET INSTRUCTIONS KANSAS PACKET ALL LOCATIONS EXCEPT HIGHLANDS AND SANTA FE TRAIL All of our programs are licensed by the Kansas Department of Health and Environment. This is a set of documents which is required by state

More information

12111 NE First Street, Bellevue, Washington / P.O. Box 90010, Bellevue, Washington

12111 NE First Street, Bellevue, Washington / P.O. Box 90010, Bellevue, Washington Dear Parents/Guardians, January 18, 2017 Thank you for allowing your student to attend the SHOUT Experience. On Tuesday, March 28, 2017 the Bellevue School District will be hosting a leadership experience

More information

2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA

2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA 2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA CONTACT INFORMATION Camper s Name: Grade entering Fall 2018: Gender: Female Male Not specified DOB: Age as of 1st day of camp: Address: City: Zip

More information

ZooCrew Registration Packet Summer ZooCrew

ZooCrew Registration Packet Summer ZooCrew Summer ZooCrew Check the weeks you would like to sign your child(ren) up for ZooCrew: 4 & 5 year olds* Week of 7/18 In My Backyard Week of 8/1 Once Upon a Story Week of 8/15 Where the Wild Things Are 6

More information

August 19-24, 2014 (Tuesday-Sunday)

August 19-24, 2014 (Tuesday-Sunday) What is EDGE Adventure Camp? A five day Catholic camp with sports & activities including canoeing, kayaking, giant rope swing, water sports and more! Live music, catechesis, Mass, praise & worship and

More information

RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria

RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, 2015 Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria February, 2015 Dear Parents: After several years of 7 th graders

More information

Student General Information: Parent: Phone: Work Phone: Medical Information. You must attach a copy of front and back of current insurance card

Student General Information: Parent: Phone: Work Phone: Medical Information. You must attach a copy of front and back of current insurance card Field Trip: Dates: Sponsor: Student General Information: Student Name: Date: DOB: Address: Parent: Phone: Work Phone: Parent: Phone: Work Phone: Medical Information Physician: Phone: Date of last Tetnus,

More information

Group Dynamix Lock-In

Group Dynamix Lock-In Group Dynamix Lock-In Group Dynamix lock-ins are certain to be tons of fun. Just imagine several hours of exciting group activities that are guaranteed to keep you going all night long. Group activities

More information

CANOE EXPLORATION ON THE ELKHORN RIVERS OF LIFE JOHN 7:38

CANOE EXPLORATION ON THE ELKHORN RIVERS OF LIFE JOHN 7:38 CANOE EXPLORATION ON THE ELKHORN RIVERS OF LIFE JOHN 7:38 LOCATION U S HWY 127 N. FRANKFORT KY. AT-- STILL WATERS CAMP GROUND ACTION CAMP MAY 2-3 HIGH SCHOOL AGE & UP Boys Discovery and Adventure Rangers

More information

January 27 th 7:30am- 7:00pm(ish)

January 27 th 7:30am- 7:00pm(ish) A Little Bit of Faith, A Little Bit of Fun! January 27 th 7:30am- 7:00pm(ish) $25 for the Day! Teens are invited to our Winter Trip for a Mini-Retreat, visit the Gonzaga campus, and enjoy some Laser Tag

More information

SHAWNEE COUNTY SHERIFF S OFFICE WORKING TOGETHER FOR OUR KIDS

SHAWNEE COUNTY SHERIFF S OFFICE WORKING TOGETHER FOR OUR KIDS SHAWNEE COUNTY SHERIFF S OFFICE WORKING TOGETHER FOR OUR KIDS JUNE 4 th - 8 th JUNE 11 th - 15 th JUNE 18 th 22 nd Seaman High School Shawnee Heights High School Washburn Rural High School 8:00am-12:00pm

More information

Applicant must have taken the ACT/SAT Test at least once and submit their scores.

Applicant must have taken the ACT/SAT Test at least once and submit their scores. HENDERSON STATE UNIVERSITY SUMMER INSTITUTE STUDENT INFORMATION SHEET Sunday, July 8-Thursday, July 12, 2018 Application deadline for ALL applications is Friday, June 4, 2018 ELIGIBILITY CRITERIA Applicant

More information

CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018

CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018 1 CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018 CHECK LIST & INSTRUCTIONS FOR COMPLETING THIS FORM: This Medical Form is required EACH YEAR for every participant of Camp Wastahi. As a requirement

More information

NORTH CAROLINA 4-H VOLUNTEER APPLICATION

NORTH CAROLINA 4-H VOLUNTEER APPLICATION NORTH CAROLINA 4-H VOLUNTEER APPLICATION PERSONAL INFORMATION First Name: Middle Name: Last Name: Suffix: Preferred Name: Mailing Address: Mailing Address 2: City: State: Zip: Gender: Male Years in 4-H:

More information

SAN ANTONIO DE PADUA CHURCH YOUTH MINISTRY REGISTRATION FORM

SAN ANTONIO DE PADUA CHURCH YOUTH MINISTRY REGISTRATION FORM SAN ANTONIO DE PADUA CHURCH 2016-2017 YOUTH MINISTRY REGISTRATION FORM Are you a registered parishioner: Yes No If no, name of parish where family is registered: Section 1 - Parent/Guardian Information

More information

ROCK PAPERWORK CHECKLIST

ROCK PAPERWORK CHECKLIST ROCK PAPERWORK CHECKLIST Thank you for registering for the ROCK Before/After School Program, a ministry of Zionsville United Methodist Church. Please make sure you have each of the following documents

More information

Clermont-Hamilton Cloverbud Day Camp. Sunday, June 7, :00 a.m. 3:00 p.m. What is Cloverbud Day Camp? Activities.

Clermont-Hamilton Cloverbud Day Camp. Sunday, June 7, :00 a.m. 3:00 p.m. What is Cloverbud Day Camp? Activities. Clermont-Hamilton Cloverbud Day Camp Sunday, June 7, 2015 10:00 a.m. 3:00 p.m. 4-H Camp Graham Craft Projects Camp Songs Field Games Story Time And much more! Activities Pool Games Circus Science Making

More information

MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM June 11 - June 17, 2017 Sunnyhill Adventures - Dittmer, Missouri

MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM June 11 - June 17, 2017 Sunnyhill Adventures - Dittmer, Missouri MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM June 11 - June 17, 2017 Sunnyhill Adventures - Dittmer, Missouri APPLICANT NAME: (Last) (First) (Middle) ADDRESS: CITY: STATE: ZIP: EMAIL ADDRESS: AGE:

More information

Policy Title: Administration of Medication by School Personnel Policy No:

Policy Title: Administration of Medication by School Personnel Policy No: Policy Title: Administration of Medication by School Personnel Policy No: 504.14 The Board of Trustees recognizes that students attending schools in St. Maries Joint School District No. 41 may be required

More information

4-H Shooting Sports Instructor

4-H Shooting Sports Instructor Training 4-H Shooting Sports Instructor Certification Training for 4-H Certified Adult Volunteers in the 4-H Shooting Sports Program Date: May 27-28, 2016 Location: Cost: State 4-H Office and Stillwater

More information

NOT SIGNED/INCLUDED as my student does not self-administer medicine

NOT SIGNED/INCLUDED as my student does not self-administer medicine 2017-18 School Year Hello, and welcome to Ridge Point High School Band and Guard! The attached forms help us manage and support the more than 170 members of the Band and Guard. Please sign and return all

More information

BACK FOR ANOTHER Come and YEAR celebrate

BACK FOR ANOTHER Come and YEAR celebrate The All Days are Happy Days summer day camp offers a week of fun, learning, and activities for the child with Attention Deficit Hyperactivity Disorder. The University of Tennessee, Boling Center for Developmental

More information

ROSIE S GIRLS OVERNIGHT LEADERSHIP PROGRAM

ROSIE S GIRLS OVERNIGHT LEADERSHIP PROGRAM 2017 REGISTRATION FORMS Rosie s Girls STEM Leadership Camps Vermont Tech - Randolph Center Followed by a Leadership Mentor Program For girls (Vermont residents only) entering 9 th -10 th grades fall 2017

More information

CAMPER REGISTRATION FORM INSTRUCTIONS

CAMPER REGISTRATION FORM INSTRUCTIONS T O T H E D A Y C A M P CAMPER REGISTRATION FORM INSTRUCTIONS Thank you for choosing the Flock to the Kroc Day Camp for this summer. Our payment process will be completed online this year. Please follow

More information

YMCA OF GREATER NEW YORK SUMMER DAY CAMP REGISTRATION FORM

YMCA OF GREATER NEW YORK SUMMER DAY CAMP REGISTRATION FORM Branch: Camp Site: Camp Type: PARTICIPANT INFO: Date of Birth: Gender: Grade in September 2018: School: Home Phone: ( ) Email: My child will: Be picked up Walk Home (Only campers 10 years or older. Please

More information

STUDENT MINISTRY GUIDELINES AND FORMS

STUDENT MINISTRY GUIDELINES AND FORMS STUDENT MINISTRY GUIDELINES AND FORMS Table Of Contents TRAVEL GUIDELINES FOR: Camps ~ Retreats ~ Overnight Transportation Restaurants EMERGENCIES: Emergency Procedures Medical Emergency Procedures LEADERSHIP:

More information

Dear Parent/Guardian,

Dear Parent/Guardian, Dear Parent/Guardian, Thank you for your interest in Nathan Adelson Hospice s Camp Erin. Camp will be held June 1 st 3rd, 2018. We are very excited and looking forward to another great camp experience!

More information

U.S. Army Aeromedical Research Laboratory Gains in the Education of Mathematics and Science Program PARTICIPANT APPLICATION

U.S. Army Aeromedical Research Laboratory Gains in the Education of Mathematics and Science Program PARTICIPANT APPLICATION To be considered for acceptance into the 2013 GEMS program, submit the following: 1. The Participant Application 2. The Participant Essay 3. The Participant Release Form 4. Participant Safety Information

More information

CrossTi bars Julv 1& th --19 th

CrossTi bars Julv 1& th --19 th CrossTi bars Julv 1& th --19 th COST: $160 lids' ca p $60 Deposit to Reserve Spot Limited number of scholarships available (Must pay the deposit) Contact emily@waterlooroad.org for information Child's

More information

2018 SPORTS CAMP REGISTRATION FORM

2018 SPORTS CAMP REGISTRATION FORM 2018 SPORTS CAMP REGISTRATION FORM CHILD NAME: Date of Birth Age T SHIRT SIZE: S M L XL WHAT SESSION(S) ARE YOU REGISTERING FOR (PLEASE CHECK): Jul 9 Jul 13 Jul 16 Jul 20 Jul 23 Jul 27 Aug 13 Aug 17 Aug

More information

GEMS Parent/Guardian Forms

GEMS Parent/Guardian Forms 2017-18 GEMS Parent/Guardian Forms PARENTAL/GUARDIAN AFFIRMATION I, hereby give my permission to the Indianapolis Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated for to participate in the Dr.

More information

2018 Super Summer Student Registration Form

2018 Super Summer Student Registration Form Staple a copy of your insurance card front and back to this paper 2018 Super Summer Student Registration Form Please print legibly (circle the name you normally go by) Student Personal Information Last

More information

16 Camp Alamisco

16 Camp Alamisco Theme: Following owing Jesus Camp Pastor: Jeremy Simpson YOUTH CAMP (for those who have completed grades 7 KIDS CAMP (for those who have JULY 13-16 16 (for those who have completed grades 7-12) for those

More information

MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?

MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us? MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages relating

More information

El Salvador Mission/Study Trip Application

El Salvador Mission/Study Trip Application El Salvador/Guatemala Trip Dates: July 31- Aug 10 Please print in ink (Or type and e-mail) El Salvador Mission/Study Trip Application Name: Age: Birthday: LAST FIRST MIDDLE Male Female Email Address City

More information

ORLEANS COUNTY YMCA SUMMER DAY CAMP 2014 PARTICIPANT FORMS

ORLEANS COUNTY YMCA SUMMER DAY CAMP 2014 PARTICIPANT FORMS ORLEANS COUNTY YMCA SUMMER DAY CAMP 2014 PARTICIPANT FORMS SUMMER REWIND PRICING / 0/ FOR / $28/DAY FOR $38/DAY FOR N FOR MEMBERS 5/ FOR N-MEMBERS AY FOR MEMBERS AY FOR N-MEMBERS ORLEANS COUNTY YMCA DAY

More information

Camp Connect 2018 ENROLLMENT APPLICATION

Camp Connect 2018 ENROLLMENT APPLICATION ENROLLMENT APPLICATION Will a buddy be attending? Yes NO If yes, please complete buddy section Name of Camper: Date of Birth: County: * A separate Enrollment Application and Camper Portfolio must be completed

More information

Participant is a: Student Cabin Leader Adult Chaperone Teacher/School Staff PARTICIPANT INFORMATION Name Male / Female/ Other Date of Birth Age

Participant is a: Student Cabin Leader Adult Chaperone Teacher/School Staff PARTICIPANT INFORMATION Name Male / Female/ Other Date of Birth Age Registration and Health Form ** REQUIRED FOR ALL PARTICIPANTS** Please complete BOTH sides of this form legibly and in ink. Be sure to SIGN where indicated. Return to the participant s school. Please call

More information

Kairos Retreat for Teens [SFK13] September 22, 23, 24 & 25 th, 2016

Kairos Retreat for Teens [SFK13] September 22, 23, 24 & 25 th, 2016 For Juniors & Seniors in High School What is Kairos? Kairos, which means Lord s Time, is a Christian experience of prayer and reflection, run by a team of adults and trained peer leaders. St. Francis de

More information

Children s Residential Treatment Center Medical Intake Information

Children s Residential Treatment Center Medical Intake Information Children s Residential Treatment Center Medical Intake Information The following is required at/by intake: q Copy of Current Insurance Cards (Medical, Dental, or Medical Assistance) q Proof of Physical

More information

Thank you for registering for the 2016 Invasion Field Hockey Camp

Thank you for registering for the 2016 Invasion Field Hockey Camp 1 F I E L D H O C K E Y 2016 Invasion Field Hockey Camp Information Packet Thank you for registering for the 2016 Invasion Field Hockey Camp We hope that this will be a memorable and exciting experience

More information

CAMPER S NAME: DATE OF BIRTH: AGE: ADDRESS: CITY: STATE: ZIP: SCHOOL: GRADE: 2018 KROC SUMMER CAMPS

CAMPER S NAME: DATE OF BIRTH: AGE: ADDRESS: CITY: STATE: ZIP:   SCHOOL: GRADE: 2018 KROC SUMMER CAMPS Please complete one (1) per child. CONTACT INFORMATION CAMPER S NAME: DATE OF BIRTH: AGE: PARENT (GUARDIAN) NAME: CAMPER LIVES WITH (CUSTODIAL PARENT): PHONE: DAY CELL ALTERNATE ADDRESS: CITY: STATE: ZIP:

More information

HUSTON-TILLOTSON UNIVERSITY ENVIRONMENTAL RESCUE ROBOTICS CAMP REGISTRATION FORM

HUSTON-TILLOTSON UNIVERSITY ENVIRONMENTAL RESCUE ROBOTICS CAMP REGISTRATION FORM REGISTRATION FORM 9 th -12 th Grade Girls PROGRAM DATES: July 29-August 2, 2013, 9:00 am-4:00 pm. APPLICATION DEADLINE: June 7, 2013 (May 31 for early decision and scholarship opportunities) PROGRAM COST:

More information

2018 SPRING/SUMMER TACKLE FOOTBALL WAIVER FORM

2018 SPRING/SUMMER TACKLE FOOTBALL WAIVER FORM 2018 SPRING/SUMMER TACKLE FOOTBALL WAIVER FORM AGREEMENT REGARDING PARTICIPATION, ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNIFICATION Student name: Birth date: Grade: The purpose of

More information

MESA COMMUNITY COLLEGE. Information Packet 2018 YOUTH COLLEGE. Workshop I & II - Please fill out the following forms and bring to your Audition Time:

MESA COMMUNITY COLLEGE. Information Packet 2018 YOUTH COLLEGE. Workshop I & II - Please fill out the following forms and bring to your Audition Time: MESA COMMUNITY COLLEGE Information Packet 2018 YOUTH COLLEGE Workshop I & II - Please fill out the following forms and bring to your Audition Time: o 14 years and older Need to provide picture ID for Student

More information

Downers Grove Park District

Downers Grove Park District Participant s Name Downers Grove Park District Summer Camp Forms 2018 Please check the camp(s) your child will attend to ensure we have emergency information at each camp: Adventure Camp (K-2: Lincoln

More information

Student Application. Student Name Nick Name. Address. City State Zip Code. Address

Student Application. Student Name Nick Name. Address. City State Zip Code.  Address General Information (PLEASE PRINT CLEARLY) Residential Intensive Summer Education (RISE ) Program 2012 Student Application Cal Poly Pomona Office of Admission and Outreach, Building 98-4 th floor Attn:

More information