2018 STUDENT REGISTRATION MEDICAL / LIABILITY RELEASE FORM

Transcription

1 LAKE TOMAHAWK CHRISTIAN RETREAT CENTER 408 Lake Tomahawk Rd., Livingston, Texas (Fax) STUDENT REGISTRATION MEDICAL / LIABILITY RELEASE FORM INSTRUCTIONS: Complete the Registration form in its entirety. All requested information is applicable. Type or print legibly in Dark Ink. DATE: // Shot Record Attached: YES Camper s Name: First Middle Last (indicate name used) Social Security No.: (SS # not required but needed in case of admittance to hospital.) Address: Street City State Zip Birth Date: // Age Now : Sex: (M/F) Grade Completed 18 end of school yr: Mo. Day Year Home Phone: () Name of Church or Group with whom you are attending: City: State: Parent / Legal Guardian: Relationship to You: Parent / Legal Guardian Phone Number: Daytime () Evening () Other () Parent MEDICAL INFORMATION In the event of an accident or special health needs, it will be necessary for us to have the requested information. Please make certain that you have provided thorough and accurate medical information. Medications you take for current medical condition (asthma, allergies, etc.) Medications you take occasionally (headaches, etc.) Do you plan to bring these or any other medications to camp with you? YES NO State law requires all medications to be placed in the campus Health Center. All medications must be brought in the original bottle (prescription or over-the counter), properly labeled as prescribed by law. Health Information: Do you have, or have you had Recent Serious Injury? YES NO Recent Surgery? YES NO Chronic Medical Condition? YES NO Other Health Concerns? YES NO If YES to any of the above, please describe: Special Diet? Date of last Tetanus Shot? Allergies: Food? Drugs? Insect Stings/Bites? Other? State law requires a shot record for each person 17 years of age and younger. Person to Notify in Event of Emergency: Relationship to You: Phone Number of Contact Person: Daytime () Evening () Other () Family Physician: Medical Insurance Co.: Insured ID or Member #: Phone: () Plan or Group #: Ins. Co. Phone #: () It is recommended that you attach a photocopy of your family medical insurance card. IMPORTANT... SEE ADDITIONAL PAGES FOR MANDATORY STUDENT AND PARENTAL RELEASE Page 1 of 3 -Student Summer Non-Association Medical / Liability Release Form

2 Page 2 of 3 -Student Summer Non-Association Medical / Liability Release Form CAMP RULES 1. All medications are to be listed on the Registration/Medical Release form and taken to the Health Center and registered with the LTCRC medical staff. All medications must be in original bottle and/or container. Medications will be administered as per RX label instructions and dosage, unless written, signed, and dated parental instructions state otherwise. Students are not to share any medications, including over-the-counter medications. 2. Campers who are ill or injured must be either in the LTCRC camp office, medical clinic, or hospital. In the event of illness or injury, students will not be permitted to remain in their dorm rooms. 3. Prank supplies are not allowed (e.g. shaving cream, body paint, water balloons, water guns/blasters, flour, confetti, silly string, etc.). There are no exceptions. 4. At no time is a student to go to the lake without adult supervision. No one is allowed in the water at any time other than during specified waterfront times approved by LTCRC and in specified waterfront areas under LTCRC lifeguard supervision. Lifejackets are required for certain lakefront activities, regardless of a person s age or water safety abiity. 5. No one is allowed on the ropes course ( Tower or any part of the Zipline or Poles) at any time other than during specified ropes course times approved by LTCRC and under LTCRC supervision. 6. Drugs, alcohol, any form of tobacco, firearms, knives, or any kind of weapon, or fireworks are NOT allowed. 7. Campers are expected to reflect a Christian example by their dress. Shorts can be worn to worship but must be longer than the arm and hand when extended down the side of the person. Modest skirts and dresses are acceptable in worship, and jeans are always acceptable. Immodest shorts or tops, spaghetti strap tops, distasteful designs or messages, and other extreme clothes are not acceptable at any time. Only one-piece swimsuits are allowed. Bikinis, French cut or one piece resembling two-piece swimwear will require a dark colored t-shirt to be worn over them. Campers may be asked to change their attire if an adult feels their dress is inappropriate. SHOES MUST BE WORN AT ALL TIMES. 8. Refrain from Public Display of Affection with others. 9. Under NO circumstances are girls to be in guys rooms or guys in girls rooms. 10. No fighting is allowed. 11. Students are to respect all adult leaders and follow their instructions. All adults members of LTCRC leadership team, church leadership teams, and adult volunteers are in places of authority over all students. They have been trained in how to guide students for each particular event. 12. Everyone must attend all scheduled events. If your group is in an activity, whether in the classroom or on the athletic field, you must be with them. There are no exceptions to this unless you are injured or sick and are at the LTCRC Health Center, doctor s office or hospital. 13. Campers MUST be in the dorm by designated camp curfew. Your curfew is for your security and for your mental and physical well-being. 14. Guests are not allowed to bring pets on campus. AGREEMENT TO PARTICIPATE AND RELEASE OF LIABILITY SAN JACINTO BAPTIST ASSOCIATION d/b/a LAKE TOMAHAWK CHRISTIAN RETREAT CENTER hereinafter referred to as the "Camp" or LTCRC requires signatures below for all attendees of the Camp and all participants in any Camp activity. Attendance and Activities at Camp may include warm-ups, games, group initiative challenges, and/or other rigorous physical adventure activities as well as exposure to the elements, including animals, snakes and insects. Camp takes all reasonable precautions to ensure you have a safe and enjoyable experience. Part of the experience can be physically demanding and include varying levels of stress and anxiety, not all of which can be foreseen. The decision to attend the Camp and the decision to participate in any Camp activity at any level is at all times completely up to the camper, with permission, or the adult attendant. If there is attendance at the Camp and participation at any level in any Camp activity, there is a risk, which must be assumed by each Camper, with permission, and/or Attendee participating in the Camp activity. Depending on the programming designed by your Church or Group Sponsors, the Camp activities may include some or all of the following rigorous physical activities: Waterfront: Water Crafts, including canoes and paddle boats, Swimming, Water Toys, including but not limited to Waterslides, Water trampoline, Climbing structures and the Blob. Access to some of these water toys includes climbing heights anywhere from 12 feet to 25 feet. Access to the Wet Willy slide requires climbing the tower stairs, which extend 25 feet above the ground. The Blob climbing tower is 17 feet above the water. While the Camp provides life jackets and/or vests for all waterfront activities (with the exception of the swimming area for those swimmers demonstrating sufficient swimming proficiency as determined by the Camp) as well as certified lifeguards during all scheduled waterfront activities, inherent risks associated with participation in waterfront activities in any natural body of water range from minor bruises and scrapes to severe and potentially paralyzing injuries, including death. Rock Climbing Walls and Ziplines: As a component of the Camp s Challenge Course, two rock climbing walls may be used as a component of your Church or Group s programming. These rock climbing walls permit campers and adult participants to climb to heights of 40 feet above the ground. Rock climbing harnesses and spotters will be utilized during this activity. In addition, Ziplines extending 900 feet over the lake require climbing a tower 55 feet high before ziplining across a portion of the lake to the endpoint, 12 feet above the ground. The Ziplines and Rock climbing walls are supervised by certified camp instructors and appropriate harnesses and equipment will be utilized on the ziplines. While the Camp provides appropriate safety equipment and certified staff during all scheduled rock climbing and ziplining activities, inherent risks associated with participation in rock climbing and ziplining activities may range from minor bruises and scrapes to severe and potentially paralyzing injuries, including death. Recreational Sports and Outdoor Activities: Additional programming by your Church or Group may include camp activities including Backpacking, Camping, Basketball, Football, Baseball, Softball, Volleyball, and any and all other camp and recreational sports, activities and games. Your participation in said recreational sports and activities is at your own risk. While unlikely, risks associated with participation in said activities range from minor bruises and scrapes to severe and potentially paralyzing injuries, including death. IMPORTANT... SEE ADDITIONAL PAGE FOR MANDATORY RELEASE and SIGNATURE:

3 Page 3 of 3 -Student Summer Non-Association Medical / Liability Release AGREEMENT TO PARTICIPATE AND RELEASE OF LIABILITY (Continued) In order to participate in each of the three categories of Camp activities described above, your consent to release the Camp from any liability, including liability as a result of the Camp s own negligence, is required by the adult participant or the parent or legal guardian of a minor participant. Absent completion of all documentation, participation in Camp activities is prohibited. "I understand that attendance at the Camp and participation in any Camp activity may be physically and emotionally demanding. I recognize the inherent risk of physical and/or emotional injury of attending Camp and participating in any and/or all Camp activities. I understand that each participant must assume the risk of any injury, physical and/or emotional, and any financial responsibility that could result from attending Camp and participating in any Camp Activity. I agree to assume such risks and such responsibility. I, on my behalf, and on behalf of my heirs and assigns, hereby release, discharge, indemnify and hold LTCRC harmless from any and all claims, physical and emotional, including bodily injury, I sustain in connection with my attendance at Camp and my participation in any and all Camp activities, including WA- TERFRONT ACTIVITIES, ROCK CLIMBING AND ZIPLINING AND/OR RECREATIONAL AND OUTDOOR ACTIVITIES. Specifically, I hereby intend to fully release, discharge, indemnify and hold LTCRC, its owners, operators, members, managers, employees, trustees, insurers and staff harmless from all said claims or injuries, including death, whether known or unknown, temporary or permanent, arising out of LTCRC s own negligence, breach of duty, misrepresentations, negligent or otherwise, and/or arising out of the condition of its premises. I understand the directors of Lake Tomahawk Christian Retreat Center reserve the right to dismiss, without refund, any participant whose influence is detrimental to the operation of the camp, as determined by the discretion of the directors. I understand that the use of alcohol, tobacco products, and illegal drugs is strictly prohibited at all Lake Tomahawk Christian Retreat Center programs. RELEASE OF PHOTOGRAPHS, VIDEO, AUDIO AND RELATED MEDIA FORMATS TO CAMP: Please acknowledge your release of the Camp to photograph and/or use photographs of your child for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and activities of Camp. Please mark the appropriate box: Permission Granted Permission Denied OPPORTUNITY TO DECLINE PARTICIPATION IN SPECIFIED CAMP ACTIVITIES: While a participant may decline to participate in any camp activity, if you feel that there are any activities in which your minor child should not be permitted to participate (e.g. Waterfront Activities, Rock Climbing Walls and Ziplines, Recreational Sports and Outdoor Activities), please specify on the line below. I do not wish my minor child to participate in. REQUIRED SIGNATURE: The signature provided confirms I have read the Camp Rules, the Agreement to Participate and Release of Liability, the Release of Photographs, Video, Audio and Related Media Formats (or had someone read them to me) and freely and voluntarily agree to the terms and conditions of this Release in order to participate in any and all Camp Activities unless specified above. I acknowledge the information I have given is correct to the best of my knowledge. Furthermore, I give permission for Lake Tomahawk Christian Retreat Center staff to provide and authorize any medical treatment necessary. X Required Participant Signature Print Name Clearly Date X Required Parent/Guardian of Minor Participant Print Name Clearly Date

4 MEDICAL TREATMENT RELEASE IN THE EVENT OF AN ACCIDENT OR SPECIAL HEALTH NEEDS, IT WILL BE NECESSARY FOR US TO HAVE THE REQUESTED INFORMATION. PLEASE MAKE CERTAIN THAT YOU HAVE PROVIDED THOROUGH AND ACCURATE MEDICAL INFORMATION.IT IS RECOMMENDED THAT YOU ATTACH A PHOTOCOPY OF YOUR FAMILY MEDICAL INSURANCE CARD. Name: Birth Date: Age: Sex: (M/F) First Middle Last Mo. Day Year Church: City: Dates at Zephyr: to Person to Notify in Event of Emergency: Relationship to You: Phone Number of Contact Person: Daytime Evening Other If unable to reach above person: Notify Relationship to You: Phone Number of Contact Person: Daytime Evening Other Family Physician: Medical Insurance Co.: Insured ID or Member #: Phone: Plan or Group #: Ins. Co. Phone #: MEDICAL INFORMATION Significant Allergies (specify) Food: Insect Sting: Medicine/Drug: Plant/Pollen: Other: Special Diet: Recent Surgery? Date of last Tetanus Shot? Immunizations Current? Diseases, Chronic or Recurring Illness: (Check all that apply, explain) Asthma: Bleeding Disorder: Joint or Back Problems: Diabetes: Epilepsy: Heart Condition: Seizures: Stomach Condition: Emotional: HEALTH CARE AND CAMP PERMISSION INITIAL & SIGN THE STATEMENTS BELOW. I give permission for first aid techniques and simple health care to be administered as the need arises. I understand in the event of any serious injury or illness on my part the camp officials reserve the right to seek professional medical attention including but not limited to consultation with medical director, EMS transportation, and hospitalization. I give permission for myself or my child/ward, in consultation with the Camp Health Supervisor and/or the medical director s standing orders, to take the following medications as indicated by checking below: acetaminophen (i.e. Tylenol) Ibuprofen (i.e. Advil) decongestant (i.e. Sudafed) antihistamine (i.e. Benadryl, Claritin) antihistamine cream antibacterial ointment antacid tablet (i.e. Tums) additional medications as indicated/prescribed by the TPCC Medical Director PLEASE ATTACH A COPY OF YOUR INSURANCE CARD I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that I or my child/ward am/is in acceptable heath, physical ability, and emotionally ready to fully participate in camp or retreat activities. I grant my permission to participate in all activities associated with the enrolled event with the exceptions of those that are noted. I, being the legal guardian of (if applicable) give my permission to Lake Tomahawk Baptist Encampment management, medical staff, and/or the group director to provide medical treatment that may be deemed necessary to insure the well-being of myself/the named camper. I do hereby release and forever discharge all from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in Lake Tomahawk Baptist Encampment sponsored activities. X Signature Date Phone Number

5 MEDICATION ADMINISTRATION AUTHORIZATION (STUDENTS ONLY) This form is to be completed and submitted UPON ARRIVAL at Lake Tomahawk Baptist Encampment to the Lake Tomahawk Baptist Encampment Medical Staff WITH below de-scribed medications. Name: Birth date: Age: Sex: Male Female Church Name: Church City & State: As the parent or legal guardian of the above-named child, I give my permission to the Lake Tomahawk Baptist Encampment Medical Staff to administer as prescribed by law the listed below medication to my child. X Parents/Guardian Signature Date Daytime Phone # Evening Phone # OR As an Adult Camper/ Sponsor/Staff, I give my permission to the LTBE Medical Staff to administer as prescribed by law the listed below medication to me during my stay at Lake Tomahawk Baptist Encampment X For Prescription Medications only...please follow these guidelines: In accordance with Texas Department of Health regulations: ALL Medication that is brought to camp must be: (1) Placed in a secure location not accessible to campers, (2) Prescribed for the camper (not a sibling or parent), (3) In the original container with all labels intact, and (4) Correct current dosage. Dosage of non-prescription medication may not exceed product recommendation without doctor s written orders. Lake Tomahawk staff request that you do not send overthe-counter medications (i.e. Tylenol, Ibuprofen, Benadryl, etc). These types of medications are provided by Lake Tomahawk Baptist Encampment). Name of Medication: Purpose for medication use (e.g. allergies, asthma, antibiotic) Form of medication: Tablet Pill Capsule Liquid Inhalation Other (specify) - Dosage (amount to be given): How often or at what time: Remarks or special instructions: Name of Medication: Purpose for medication use (e.g. allergies, asthma, antibiotic) Form of medication: Tablet Pill Capsule Liquid Inhalation Other (specify) - Dosage (amount to be given): How often or at what time: Remarks or special instructions: Name of Medication: Purpose for medication use (e.g. allergies, asthma, antibiotic) Form of medication: Tablet Pill Capsule Liquid Inhalation Other (specify) - Dosage (amount to be given): How often or at what time: Remarks or special instructions: If necessary, make additional copies of this blank Medication Form in order to provide requested information for each medication. All Medication Release/ Administration Forms and medication(s) to be administered should be given to the church Contact Person prior to arriving at LTBE When the church group arrives at camp, the Contact Person will be responsible for bringing all medications and forms to the LTBE Office. The Forms will be reviewed by our Medical Staff to clear up any possible questions about medications or their administration. To make it easier for the church Contact Person, the parent/or student should put their medications and signed Medication Administration Authorization forms in a zip-lock type plastic bag with the student s name and church written with a marker on the outside of the bag. Parents should emphasize to their child(ren) the responsibility of reporting to the camp Health Center for their medications while at camp. 2

6 LIABILITY RELEASE AND INDEMNITY I, and my parents or legal guardian (if a minor), am/are fully informed about and aware that during my stay at Lake Tomahawk Baptist Encampment, Livingston,TX also known as LTBE in connection with an event of the Southern Baptists of Texas Convention (SBTC), certain risks and dangers will occur. These include, but are not limited to, the hazards that arise from being in a wilderness area, the forces of nature and other hazards arising out of the content of this program which include, but are not limited to, volleyball, soccer, soft-ball, basketball, archery range, wilderness hiking, swimming, use of watercrafts, and a challenge course which has a climbing wall, zip lines, high and low elements, and a team power pole. In consideration of LTBE and SBTC providing and my willingness to engage in these rigorous activities and a special environment, I have and do hereby hold LTBE and SBTC their owners, officers, directors, trustees, agents, employees, and/or volunteers, harmless from any and all claims, liabilities, suits, actions, causes, damages or losses and demands of every kind and nature whatsoever, including without limitation, all costs and attorney s fees, which may arise from or in connection with my stay or participation in any activities arranged for me by my organization or my group leaders, LTBE or SBTC. Injuries may include, but are not limited to, emotional injuries, physical injuries, or death. The terms hereby shall serve as a release and assumption of risk for me, my heirs, executors, administrators, and for all members of my family. I authorize the use of my or my child s photograph or video on the LTBE or the SBTC website or brochures for camp updates and communication. In case of an accident or illness, I authorize LTBE s nurse or first aid personnel to ex-amine, treat, or administer medications for any illness or injury to my child as deemed necessary. In the event of an emergency involving my child and if I cannot be reached by telephone, I authorize such persons to obtain any medical care (including hospitalization, injection, anesthesia, and surgery) from a licensed, certified, or authorized health care provider for my child as deemed necessary. I accept sole responsibility for the payment of any medical care for me or my child. I hereby release, indemnify and hold harmless LTBE and the SBTC, their owners, officers, directors, trustees, agents, employees, and/or volunteers from and against any and all claims, liabilities, or damages arising from any act, omission, negligence, or gross negligence of any such health care provider or of LTBE, or the SBTC, their owners, officers, directors, trustees, agents, employees or volunteers. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Texas and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CON- TENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and have understood. X X Signature Date Parent or Legal Guardian Signature (if minor) Date