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

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1 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 may attend may attend with guardian but camp is not accreted as Action Camp for those. Friday schedule Saturday Schedule 6:00 pm till? * Registration and Camp setup 7:00 pm * Camp Fire Chili for all 9:00 pm * Devotion 10:00 pm * lights out 7:00 am * rise and shine & breakfast 8:00 am * prepare your meals and drinks for trip 8:30 am * depart for trip 11:30 am * we will stop on creek for lunch 4:00 pm * we will return to camp and load your canoe before departing PLEASE.

2 D I S T R I C T I T E M S P R O V I D E D (1. SUPPER, BREAKFAST, and day trip foods and water. (2. CANOES, PATTALES, & LIFE-JACKETS (3. CAMPING AREA WITH RESTROOMS AND SHOWERS P E R S O N A L I T E M S N E E D E D (1. FOOD ITEMS FOR YOUR LUNCH & DRINKS (2. LARGE ZIPLOCK BAGS FOR PERSONAL ITEMS (3. Personal first-aid kit with thermo blanket (4. Extra change of clothes, sandals and or etc (5. Bible (6. Tent for overnight camping (7.Insurance and release forms are a must

3 A c t i o n C a m p O u t p o s t R e g i s t r a t i o n F o r m May Action Camp on the Elkhorn Still Waters Camp Ground Address U S Hwy 127 North Frankfort, Ky. Each Young man High School age not necessary Royal Ranger may attend: He must be Expedition Ranger age and have this form completed to attend Action Camps. Younger boys must have guardian present at the camp. Adults: This may be any man eighteen years of age or older with Pastor Approval Form. DO NOT DELAY-REGISTER NOW! Outpost # Phone Contact Person_ cell Church name _Phone Address City State Zip Cost is $20.00 Per Person: NO REFUNDS PLEASE! Number of Adults Number of Boys Total $ Mail This form to Gilbert Kerby at or snail mail to 2005 Massie School Road LaGrange, Ky You may text confirmation only at and bring with you all forms. We have a limited amount of canoes and after they are filled the cost will be $30.00 each Person. So get your registration confirmed ASAP to insure the low cost of $20.00 per person.

4 Permission Form for Boys (Boy s name) is high school age and has my permission to participate in all activities at the Kentucky District Royal Ranger s Action Camp. Please check a box. YES NO If no, please inform his commander in writing as to which events he shall not be a part of. If emergency service involving medical action or treatment is required and neither the parent nor family physician can be contacted for consent, I hereby consent to the rendering of emergency medical treatment deemed appropriate in the opinion of the doctor rendering such services. Name of Parent or Legal Guardian Signature Day Phone Night Family Physician s Name Phone Phone In Case of Emergency Notify: Name Address Day Phone Alternate Contact - Must be different from above. City Night Phone The following insurance information is not required but may be helpful. Your Health and/or Accident Insurance Company Name of Company Policy #: This form must be completed and turned in to Registration upon arrival. Do not mail this form with pre-registration form. It will be returned to the outpost leaders when you depart camp. Each boy must be high school age and have this form completed to attend Kentucky District Royal Ranger s Action Camp.

5 Personal Medical Record Applicant s Full Name In case of emergency please notify: Last Name (please print) First Name Insurance Information Health Insurance Company s Name Policy Number Certificate Number Effective date of coverage Daytime Contact Phone Number Evening Contact Phone Number Health Insurance Company s Phone Number General Information: Health History To be completed by the applicant (if over 18) or by a parent/guardian if the applicant is a minor (under age 18). Has the applicant experienced the following? Check Yes or No. A Personal Medical Record Sinus condition yes no Shortness of breath yes no Exposed to infectious: mustbecompletedbyeach Ear problem yes no Skin infection yes no Disease past 3 weeks yes no applicant for participation. Lung problem yes no Hearing difficulty yes no Hepatitis past 6 months yes no Records for minors (under Heart trouble yes no Bad eyesight yes no Any disorder preventing age18)mustincludeaparent High blood yes no Wear contact lenses yes no strenuous activity? yes no or guardian s signature. Royal Allergy-Asthma yes no Any medical care in the Taking prescription Rangers office reserves the Fainting or dizzy yes no past year? yes no medicine? yes no righttoacceptorrejectany Diabetes yes no Any surgery within past Any reaction to drugs or medicine person based upon his medical Appendix yes no year? yes no or any type? yes no health. Special diet required? yes no Food or drug allergies Give latest date of inoculation or vaccination against following: I am currently taking the following medications Remarks and medical facts: Tetanus Small Pox Measles Typhoid Diphtheria Polio Special dietary Birth Height Weight Additional remarks Parent/Guardian s Name (Please Print) ( ) Parent / Guardian s Address Parent/Guardian s Area Code and Phone Number City State Zip Required Release Signatures Parent/Legal Guardian Consent & Model Release (Required for all applicants under 18 years of age) I, the undersigned, as parent or legal guardian of the above named minor do hereby consent to his participation in this event and authorize the use of emergency medical care at the discretion of the adult event leadership. I further acknowledge my understanding that media footage, including audio, video and photos, may be recorded at this event for future promotional use and hereby consent to the use of such items containing images of my child in any form and relinquish all rights of ownership or compensation. It is further understood that acceptance of these terms is a condition of my child s participation in this event. Print Complete Name of Minor Parent/Legal Guardian Signature Pastor s Certification (Required for all applicants 18 years of age or older) I, the undersigned, as Pastor of the above named adult participant do hereby acknowledge that the individual has been properly screened and approved for children or youth work in our church and provide my unqualified endorsement to his/her participation in this event. Pastor s Signature Applicant s Signature (Required for all applicants) I, the undersigned, hereby acknowledge that to the best of my knowledge, I qualify for participation in this event and do hereby agree to abide by the rules and standards established for this event by its appointed leadership. I acknowledge that the information provided on my Personal Medical Record is true and correct and I consent to the administration of emergency medical treatment at the discretion of the event leadership. I further acknowledge my understanding that media footage, including audio, video and photos, may be recorded at the event for future promotional use and hereby consent to the use of such items containing images of me in any form and relinquish all rights of ownership or compensation. Applicant Signature

6 Adult Screening Form In recent years, churches have been sued because of child abuse or molestation occurring in church youth or children s programs. In most of these cases, the plaintiffs allege one or both of the following: 1. The church was negligent in hiring the molester to work with minors (i.e. the church hired and/or used volunteers without any screening or evaluation). 2. The church was negligent in supervising the individual. Completion and submission of this screening form meets one of the requirements that show the Kentucky District Royal Rangers is screening adult leaders who will be attending events. It will be used to help provide a safe and secure environment for those boys who participate in our program and use Kentucky District facilities. This form is to be completed and turned in upon arrival at Registration by all adults eighteen (18) years old or older, for any position involved in the supervision of boys at the Kentucky District events. Adult s Name Address Home Phone City State Zip Church Name Outpost # If a commander number of years in Royal Rangers Briefly Explain Your Church Involvement s: Required Release Signatures Pastor s Certification (Required for all applicants 18 years of age or older) I, the undersigned, as Pastor of the above named adult participant do hereby acknowledge that the individual has been properly screened and approved for children or youth work in our church and provide my unqualified endorsement to his/her participation in this event. X Pastor ssignature Applicant s Signature (Required for all applicants) I, the undersigned, hereby acknowledge that to the best of my knowledge, I qualify for participation in this event and do hereby agree to abide by the rules and standards established for this event by its appointed leadership. I acknowledge that the information provided on my Personal Medical Record is true and correct and I consent to the administration of emergency medical treatment at the discretion of the event leadership. I further acknowledge my understanding that media footage, including audio, video and photos, may be recorded at the event for future promotional use and hereby consent to the use of such items containing images of me in any form and relinquish all rights of ownership or compensation. X ApplicantSignature

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