FIRST BAPTIST FORNEY JUNE 22 nd TO JUNE 26 th FULL PAYMENT FOR ALL IS DUE BY JUNE 7TH

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1 CAMP GAP 2015 FIRST BAPTIST FORNEY JUNE 22 nd TO JUNE 26 th EARLY RATE (March 22 nd May 3 rd ) $205 REGULAR RATE (May 4 th May 31 st ) $230 LATE RATE (June 1 st June 7 th ) $255 FULL PAYMENT FOR ALL IS DUE BY JUNE 7TH Camp GAP is for all who have COMPLETED 3 rd through 6 th grade Your registration is secure when a fully completed registration form and $95 deposit has been submitted to the church office You and your friends will want to register and pay the deposit as early as possible We have a limited number of available spots All registrations completed by May 31 st will include a backpack and a water bottle A $50 discount will be applied for the second child registered from the same household Copies of the immunization records are not required If all immunizations are current, please simply write current next to the Tetanus Shot and Current Immunization fields on page 2 of the 2015 Camper Registration Form A printable version of the registration forms can be accessed from our church website at All Parents and Campers must attend only one of the mandatory camp orientation meetings Wednesday, June 10 th at 7:30 pm in the Children s Event Center (CEC) Wednesday, June 17 th at 7:30 pm in the Children s Event Center (CEC) PARENTS Please contact Keri Burke if you are interested in serving as a Camp GAP Shepherd

2 Page 1 of 2 MT. LEBANON ENCAMPMENT PO Box Cedar Hill, Texas (Fax) CAMPER REGISTRATION & HEALTH FORM T-Shirt Sizes Youth L - (Preteen camp only) Adults Sizes - S M L XL XXL XXXL Name: Date of Camp: _Sex: (M/F) Birth Date: Age: Grade Completed by End of School Year 2015 Street Address: City _Zip Name of Church Camper Is Attending Camp With: City Parent /Legal Guardian: Relationship: Phone Number: Daytime _ Evening Cell Parent /Legal Guardian Emergency Contact Information Other Than Parent/ Legal Guardian: Name: Cell Relationship PARENT/ LEGAL GUARDIAN S STATEMENT OF PARTICIPATION, ASSUMPTION OF RISK, AND RELEASE OF LIABILITY 1. ACKNOWLEDGMENT OF INHERENT RISKS I certify that I am aware of the inherent risks associated with outdoor camp activities, as well as the inherent risks of being on camp property. Notwithstanding, I hereby give my child permission to participate in all camp activities. Further, in consideration for Mt. Lebanon agreeing to accept the above named child as a camper, I hereby personally assume all risks in connection with my child s attendance and participation in the events at Mt. Lebanon. 2. ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY In the event that my child is injured on camp property or during camp activities, I acknowledge that I shall be personally liable for, and agree to pay, all costs and associated expenses incurred in connection with medical and/or dental services rendered to my child in response to said injury. 3. LIMITATIONS ON INSURANCE COVERAGE I understand that my family/personal health and accident insurance will be the primary coverage. 4. RELEASE AND HOLD HARMLESS AGREEMENT I agree to release and hold harmless the Dallas Baptist Association, Mt. Lebanon Encampment, it s trustees, employees, agents, and representatives for any injury, harm, or other damage by any occurrence in connection with my child s participation in camp activities in any form or fashion. I further agree to release and hold harmless Dallas Baptist Association, Mt. Lebanon Encampment, it s trustees, employees, agents, and representatives from any claim by me, or my family, estate, heirs or assigns out of my child s participation in activities at Mt. Lebanon. 5. PRE-AUTHORIZATION FOR MEDICAL TREATMENT I hereby authorize any medical and/ or surgical treatment, including but not limited to hospital care, to be rendered to my child, as needed in the judgment of the treating physician, who is chosen by the Camp Director or any employee working under him/her, as circumstances require. I further authorize the Mt. Lebanon health staff to render first-aid and to administer medications as prescribed and programmed on the Dosage & Frequency Chart, executed by the parent or guardian. 6. ACKNOWLEDGMENT OF RESPONSIBILITY FOR DAMAGES I agree that I am financially responsible for any damage to camp property caused by my child, including any acts of graffiti. 7. CONSENT TO ADDRESS DISCIPLINARY PROBLEMS The above named camper agrees to obey and observe all camp rules, and to fully cooperate with the adult leadership, camp staff, and other campers. I agree that, if in the judgment of the adult leadership and/ or camp staff, my child becomes a discipline problem, my child may be sent home, at my expense, and that I will forfeit all camp fees paid. 8. USE OF CHILD S PHOTOGRAPH FOR PROMOTIONAL PURPOSES I agree and consent that my child s photograph may be used for promotional purposes or publicity material by Mt. Lebanon. I acknowledge that I am the parent or authorized guardian of the above named child. By my signature below, I acknowledge that I have read and understand the information set forth above, including the Release and Hold Harmless Agreement. PARENT/ GUARDIAN S SIGNATURE DATE CAMPER MEDICAL POLICY AND INSTRUCTIONS 1. All medications must be properly labeled and kept in original containers. Check expiration dates. No expired medications will be given. 2. All prescription and non-prescription medications must be presented to camp health center personnel upon arrival at Mt. Lebanon. 3. All medications must be stored and dispensed from the camp health center (except EpiPens or emergency inhalers). Campers are not allowed to keep or self-administer any medication in accordance with Texas Department of State Health Services regulations. 4. Diabetics must bring a copy of their Diabetes Management Plan. 5. Non-prescription medications such as vitamin supplements or pain relievers will be given only according to the age and dosage restrictions/instructions listed on the package unless a doctor s order is provided. 6. EpiPens or emergency inhalers may be kept with the camper. (Please send an extra one to be kept in the health center) Health center personnel must be notified immediately when a camper uses an EpiPen. If asthma symptoms are not completely relieved the camper must be brought to the health center for evaluation. 7. List any medical problem, medical alert, allergy, or other relevant health concern/issue under General Health Information. 8. List all medications, dosage and indicate after breakfast, lunch, dinner or bedtime on the Medication Dosage and Frequency Chart. 9. Place all medications and a copy of Page 2 of this form in a heavy-duty, quart sized zip-lock bag with the camper s name and name of church written with a permanent black marker on the outside of the bag.

3 Camp Name: Date: Camper s Name: Church _ INSURANCE INFORMATION (You may attach a photocopy of your current Health/Accident Insurance Card.) Insured Member s Name: Member ID Camper s Father s Date of Birth Camper s Mother s Date of Birth Health Insurance Provider: Group ID Health Insurance Provider Phone Number(s): Primary Care Physician: Phone: GENERAL HEALTH INFORMATION (If necessary, attach additional copies of information which address camper health concerns.) List any health concern/issue that would be relevant to an attending physician in the case of an emergency: List any chronic or recurring illnesses or diseases: List any food, medicine, or other significant allergies: List any pre-existing injuries which occurred BEFORE attending camp: Date of last tetanus shot: Attach current shot record _ NON- PRESCRIPTION MEDICATIONS I give my permission to the camp s health supervisor, or other health center staff, to administer non-prescription, over-the-counter medications to my child based on symptoms (not a diagnosis). For example, but not limited to, Tylenol or ibuprofen, for mild fever or pain; Benadryl or Claritin, for allergy symptoms; Pepto-Bismol, for diarrhea; cortisone cream, for bug bites; calamine, for poison ivy; and so on. Parent/ Guardian s Signature Date MEDICATION DOSAGE & FREQUENCY CHART Place all medications and a copy of this page in a heavy-duty, quart sized zip-lock bag. Print the camper s name and name of church on the outside of the zip-lock bag using a permanent black marker. If necessary, make additional copies of the Dosage and Frequency Chart. Medication Dosage/Time Monday Tuesday Wednesday Thursday Friday Page 2 of 2

4 RELEASE FORM First Baptist Forney CAMP GAP CHILD S NAME: GRADE: has my permission to engage in prescribed activities, except as noted by me (see below). In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by an adult leader in charge, to order injection, surgery or any other medical treatment that may be deemed necessary to insure the well-being of the above named, due to sickness or accident while attending First Baptist Church Forney Children s Activities, or in route to or from the destination. I also authorize any adult counselor to transport my child at their discretion in case of an emergency. I authorize the use of my child s likeness and image to be used by First Baptist Church Forney. We represent to you that we and the participant hold First Baptist Church Forney, its agents, employees, volunteers and representatives harmless from all liability arising as a result of the conduct of the participant and agree to defend and indemnify First Baptist Church Forney, its agents, employees, volunteers and representatives against any claim or liability arising as a result of such conduct. I/We also do hereby agree to release and hold harmless First Baptist Church Forney, its agents, employees, volunteers and representatives of all liability of whatever nature which may arise out of or result from participation. ACTIVITY: CAMP GAP Parent/Guardian Signature: Date: Emergency Phone # s: (Home) _(Cell#1) (Cell#2)Church you regularly attend: _ Comments about activities, medical information, medication, allergies, etc. First Baptist Forney P.O. Box College St. Forney, TX / Fax:

5 WHAT TO PACK Remember to LABEL EVERYTHING BIBLE At least one change of clothes per day you may prefer two. Clothing must be modest, comfortable and cool. Shorts and t-shirts are appropriate for all activities. Boys must wear a shirt at all times except while in the pool. Clean underwear and socks for each day Comfortable shoes (tennis shoes and sandals) - Tennis shoes are needed during the day Sandals are okay for evening only - You must wear shoes at all times (except while swimming) Sleep clothes Modest Swimsuit and cover-up for swimsuit Girls Modest ONE piece or Tankini (must meet the modesty standard) Boys No cut-off shorts OPTIONAL ITEMS Bring only if you need them- Hat or bandana for outside play Laundry bag or trash bag for used clothes Swim Towel Washcloths (at least two) or a sponge for body wash Bath Towels (at least two) Separate from swim towel Sleeping bag or twin sheets/blanket and pillow - If you are using a sleeping bag, you may also want to bring a fitted twin sheet for the mattress. Hairbrush/comb, toothbrush, toothpaste, deodorant, shampoo, personal toiletries (preferably in a labeled, large Ziploc bag) Soap in a container that closes or body wash Sunscreen 2 large kitchen trash bags for personal trash at your bunk Flashlight A LOT OF QUARTERS and $1 BILLS for concession stand and gift shop. Please divide and place in separate, sealable sandwich bags labeled with camper s name/day Snacks to share in sealed Ziploc bags All medication must be turned in at the FB Forney medication table during check-in before departing on Monday morning. Prescription medicine must be in the original containers with prescription labels. Hair Dryer Curling Iron Sleep Toy Case for Glasses Disposable Camera

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