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

Transcription

1 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 I will be attending with (circle one): Woodway Campus West Campus North Campus South Campus Cypress Campus 1463 Campus Student Information: Name Address (First Name) (Middle Name) (Last Name) City St Zip Home Phone # Parent s Cell # (circle one: mom/dad) School for 6th grade (Fall 2016) Parents Names Parent s Address Birthday Gender (Circle One) Male Female Shirt Size (check one) Youth Large Youth X-Large Adult Small Adult Medium Adult Large Adult X-Large Are you a member of Second Baptist Church? Yes or No If not, where? What City? PAYMENT OPTIONS I am paying by: Cash Check (check # ) Credit Card Please check one $425 Early Bird Special (Registration by 6/30/16) $425 by 6/30/16 $475 Regular Price (After June 30) $475 CREDIT CARD INFORMATION: (Circle One) Visa Master Card American Express Discover Card Number Name as it appears on card Card Holder s Signature Expiration Billing Zip Code Cardholder s Phone Number

2 CAMP BEHAVIOR CONTRACT By signing this form, you are promising to follow these guidelines while you are at camp. Each person must sign a Behavior Contract to be able to go to camp. As a participant at Second Baptist Church 6 th Grade Camp, I agree to obey the following rules of cooperation in order to guarantee a Christian atmosphere and a good experience for all campers: 1. I will obey all requests and instructions of the Camp Directors, Staff, and Leaders. 2. I will not bring into the camp or use any video games, radios, MP3 players, ipods, ipads, cell phones, shaving cream, or other disruptive materials. 3. I will not bring any snacks, food, or candy to camp. 4. I will follow the camp schedule faithfully, being on time, in the right place, and ready to participate as the schedule indicates. This includes wake-up and lights-out times. (No one is permitted outside their cabin between lights-out and wake-up times.) 5. I will not use profane or dirty language while at camp. 6. I will participate fully in all activities of camp. 7. I will respect the property of the camp, Church, and other campers. 8. I will not participate in any activity that would hurt another camper or leader such as fighting, practical jokes, hurtful words, or gossip. 9. I will come to camp with an attitude of having fun and expecting to learn how God can use this experience in my life. 10. I understand that if at any time I repeatedly break a clearly defined camp rule or am defiant of camp leadership, I will be sent home. Camper s Name Printed Camper s Signature I have read and discussed the above Behavior Contract with my student and understand that it is my responsibility to pick up my child from camp should the camp leadership feel it necessary to send them home. Parent's Signature

3 Student: STUDENT PROFILE First Name Last Name Name one friend that your student would like to have in their cabin: Attach Recent Photo Your camp application is not complete unless a picture is attached. School attending Fall of 2016: Mom s Name: Dad s Name: Is camper living with both parents? Y / N If not, with whom? Has your student made a profession of faith in Christ? If yes, when and where? Is your student apprehensive about spending time away from home? Activities your student is interested in: Please describe any special needs, limitations or fears your student may have. All information is confidential and will be used to help us minister to your student.

4 6 TH GRADE CAMP 2016 MEDICAL INFORMATION OF A MINOR Please Print Legibly Child s Full Name: of Birth: / / Medical Information Medical History Asthma Heart Condition Diabetes Seizures/Convulsion Sleepwalking Operations/Serious Injury Frequent Nightmares Skin Conditions Bedwetting Persistent Ear Infections Constipation Other Conditions If you answered Yes to any of the above, please explain: Other Significant Past Medical History: Physical concerns, limitations or disabilities: During the past 12 months, was the Child hospitalized? have any injuries requiring medical attention? have illnesses lasting more than one week? If you answered Yes to any of the above, please explain: Has the Child ever: had a concussion, head injury, or been knocked unconscious? had a heart-related illness? If you answered Yes to any of the above, please explain: Does the Child wear any removable dental appliance (i.e. bridge, retainer)? If there is anything else we need to know regarding the physical, emotional, mental, spiritual health of the Child, please describe in detail: Has your child had mononucleosis (mono), streptococcus (strep), staphylococcus (staph), pink eye, lice, pin worms or any other highly contagious conditions in the past six months? Specify:

5 6 TH GRADE CAMP 2016 MEDICAL INFORMATION OF A MINOR-Page 2 Please Print Legibly Child s Full Name: of Birth: / / Allergies Medications Specify: Insect Stings Specify: Food Allergies Specify: Other Allergies Specify: * Does your child have an EPI PEN Dosage: 0.15mg 0.3mg Has your child ever been diagnosed or treated (inpatient or outpatient) for a Psychiatric, Psychological or Behavioral condition? Please check all that apply now or in the past: Depression Bipolar Anxiety Schizophrenia Eating Disorder Behavioral Disorder Autism Self-Injury/Injury to Others ADHD/ADD Suicidal Thoughts or Statements Substance Abuse Other If you answered Yes to any of the above, please give dates and explanation: Medications Does your child take any prescription, over-the-counter (OTC), herbal medications, vitamins or essential oils? If YES, list ALL medications and the reason for taking them: Medication Dosage Reason *Please note we will NOT administer any herbal medications, OTC, vitamins or essentials oils that have not been approved by the FDA. Immunizations of last Tetanus Shot: Are the child s immunizations current? If your child has not been fully immunized: I refuse to have my child immunized for religious or other reasons. *Lack of full medical disclosure may result in your student being sent home at the parent s/guardian s expense. Parent/Guardian Signature: Parent/Guardian Signature: Student Signature:

6 Child s Full Name: 6 TH GRADE CAMP 2016 RELEASE, WAIVER AND AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR Street Address: of Birth: / / City, State, Zip: Sex (circle one): M F Home Phone Number: Height: Weight: Mother/Guardian s Name: Street Address: City, State, Zip: Place of Employment: Home Phone: Work Phone: Cell Phone: Father/Guardian s Name: Street Address: City, State, Zip: Place of Employment: Home Phone: Work Phone: Cell Phone: *SECOND BAPTIST CHURCH DOES NOT LIMIT ACCESS OF A NON-CUSTODIAL PARENT TO A CHILD WITHOUT A SIGNED COURT ORDER. Name: Emergency Contact (IMPORTANT Indicate two persons other than parents or guardians): Relationship to Child: Home Phone: Work Phone: Cell: Name: Home Phone: Work Phone: Cell: Relationship to Child: Insurance Information Insurance Company: Policy/Group No.: Verification Phone #: of Birth of Insured: / / Name of Insured: Physician s Name: Physician s Address: Phone Number: Hospital preference: (Please see medical release. If an emergency arises, Second Baptist Church will use its best judgment in selecting a health-care provider and/or facility.) A COPY (FRONT AND BACK) OF THE CHILD S HEALTH INSURANCE CARD MUST ACCOMPANY THIS FORM

7 6 TH GRADE CAMP 2016 RELEASE, WAIVER AND AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR-Page 2 Child s Full Name: of Birth: / / RELEASE, WAIVER AND AUTHORIZATION FOR MEDICAL TREATMENT IN CONSIDERATION FOR ALLOWING THE ABOVE-NAMED CHILD TO PARTICIPATE IN ACTIVITIES AFFILIATED WITH SECOND BAPTIST CHURCH, I DO HEREBY, ON BEHALF OF THE ABOVE-NAMED CHILD, RELEASE SECOND BAPTIST CHURCH, ITS STAFF, LEADERSHIP, EMPLOYEES, AGENTS, REPRESENTATIVES, CHAPERONES, VOLUNTEERS, AND ASSIGNS; SECOND BAPTIST SCHOOL, ITS STAFF, LEADERSHIP, EMPLOYEES, AGENTS, REPRESENTATIVES, CHAPERONES, VOLUNTEERS, AND ASSIGNS, AND SECOND BAPTIST SCHOOL FOUNDATION, ITS STAFF, LEADERSHIP, EMPLOYEES, AGENTS, REPRESENTATIVES, CHAPERONES, VOLUNTEERS, AND ASSIGNS (ALL OF THE FOREGOING RELEASED PARTIES ARE COLLECTIVELY REFERRED TO AS SECOND BAPTIST CHURCH ) FROM ANY AND ALL CLAIMS AND LIABILITIES OF WHATSOEVER NATURE, BOTH INDIVIDUALLY AND COLLECTIVELY, THAT MAY ARISE FROM THE CHILD S PARTICIPATION IN ANY ACTIVITIES AFFILIATED WITH SECOND BAPTIST CHURCH, WHETHER OR NOT SUCH ACTIVITIES OCCUR ON THE PROPERTY OF SECOND BAPTIST CHURCH AND WHETHER OR NOT SUCH CLAIMS OR LIABILITIES ARISE OUT OF THE NEGLIGENCE OR OTHER CONDUCT OF SECOND BAPTIST CHURCH. I RECOGNIZE, UNDERSTAND, AND ACKNOWLEDGE THAT THE ACTIVITIES IN WHICH THE CHILD WILL OR MAY PARTICIPATE INVOLVE RISKS, INCLUDING BODILY INJURY OR EVEN DEATH, BUT I AM NEVERTHELESS VOLUNTARILY AND KNOWINGLY CONSENTING TO THE CHILD'S PARTICIPATION IN THOSE ACTIVITIES AND ARE FULLY RELEASING SECOND BAPTIST CHURCH FROM ANY AND ALL CLAIMS FOR SUCH INJURY OR DEATH. I further agree that Second Baptist Church representatives have the authority to authorize or provide such emergency medical, dental, surgical care or treatment and are authorized to make all medical, dental or surgical care decisions as may be necessary in their judgment for the Child during his/her participation in any activities affiliated with Second Baptist Church, including but not limited to a trip to 6 TH GRADE CAMP at Carolina Creek Christian Camp from on or about AUGUST 1-5, I understand that I will be financially responsible for any costs incurred in the emergency treatment and/or transportation of the Child. I understand that the above-named Child may be treated by a volunteer health care provider and that the volunteer health care provider is not administering care for or in expectation of compensation. I also understand and agree that the volunteer health care provider is immune from civil liability for any act or omission resulting in death, damage, or injury as long as the volunteer health care provider acts in good faith and in the scope of his or her duties in providing the health care services. I, THE PARENT/GUARDIAN OF THE ABOVE-NAMED CHILD, DO HEREBY GIVE OVER AND RELEASE UNTO THE STAFF, LEADERSHIP, EMPLOYEES, AGENTS, REPRESENTATIVES, CHAPERONES, VOLUNTEERS AND/OR ASSIGNS OF SECOND BAPTIST CHURCH ALL AUTHORITY AND RESPONSIBILITY TO AUTHORIZE ANY AND ALL MEDICAL TREATMENT NECESSARY FOR THE PROTECTION OF THE HEALTH AND WELL-BEING OF THE AFOREMENTIONED CHILD. THIS AUTHORIZATION SHALL AUTHORIZE ANY AND ALL MEDICAL TREATMENT BY LICENSED MEDICAL PERSONNEL, PURSUANT TO THIS MY EXPRESS AUTHORIZATION, WHETHER WRITTEN OR ORAL, OF THE STAFF, LEADERSHIP, EMPLOYEES, AGENTS, REPRESENTATIVES, CHAPERONES, VOLUNTEERS AND/OR ASSIGNS OF SECOND BAPTIST CHURCH. THIS AUTHORIZATION SHALL BE EFFECTIVE UNTIL IT IS EXPRESSLY REVOKED. SEE NEXT PAGE FOR REMAINDER OF DOCUMENT SIGNATURE REQUIRED

8 6 TH GRADE CAMP 2016 RELEASE, WAIVER AND AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR-Page 3 Child s Full Name: of Birth: / / I hereby grant permission for the staff, leadership, employees, agents, representatives, chaperones, volunteers and/or assigns of Second Baptist Church to administer over-the-counter medications, including but not limited to: Tylenol, Advil, Tums, Benadryl, Anti-Itch Cream, Triple Antibiotic Cream, Benadryl Cream, Cough Drops, Throat Spray or Lozenges. I acknowledge that the Child will be using the facilities of Second Baptist Church and/or facilities owned and operated by third parties. I further understand that the Child may be transported in vehicles and/or equipment owned, leased, or rented by Second Baptist Church and that Second Baptist Church and/or third parties may operate such vehicles and/or equipment. I hereby give my permission for the Child to ride in such vehicles and/or equipment, assume all risk of the Child s transportation, and waive any and all claims against Second Baptist Church that may arise from the Child s transportation to and from the Event. I agree that the Child will abide by all rules and will respect the staff, leadership, employees, agents, representatives, chaperones, volunteers, other children/students, and the property of Second Baptist Church or of third parties. Any and all illegal activity by the Child will be reported to the proper authorities. I have advised the Child not to engage in horseplay and to follow all directions and instructions. I further understand that I am financially responsible for any damage to public or private property caused in whole or in part by the Child and will reimburse Second Baptist Church within thirty (30) days for any expenses associated with damages or repairs. In exchange for allowing the Child to participate in the Event and activities with Second Baptist Church, Second Baptist Church has my permission to use, without compensation, any photographs, videos, graphics, recordings, or other media of the Child in including, but not limited to, advertising, website/internet, commercials, social media, or any other means of communication. I hereby waive any right of ownership to such media and waive any and all claims the Child or I may have to receive any royalty or other compensation for such use. I acknowledge that I have read and understand all aspects of this agreement and, by my signature, indicate agreement with the terms set forth in this document. I agree that copies, scans or faxes of my signature are accepted as binding. I acknowledge that this Waiver, Release, and Authorization for Medical Treatment is effective until I submit a new or updated Waiver, Release, and Authorization for Medical Treatment and I agree to provide updated information as necessary. I have had the opportunity to speak with legal counsel regarding this Waiver, Release and Medical Authorization. I represent that I am authorized to act on behalf of all parents and guardians of the Child. As consideration for allowing the Child to participate in the 6 TH GRADE CAMP 2016, on behalf of all parents and guardians of the Child and on behalf of the Child, I give up any and all claims against Second Baptist Church arising from the Child s participation in the 6 TH GRADE CAMP Parent/Guardian Signature: Parent/Guardian Signature: Student Signature:

9 Carolina Creek Christian Camp Participation Agreement & Waiver Name of Camp Participant I am above the age of 18 and am signing this agreement as the camp participant. I,, am the parent/legal guardian of the came participant, a minor. I hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child my permission to attend Carolina Creek Christian Camp. Furthermore, I consent to give my child permission to participate in all activities including, but not limited to, climbing, repelling, low rope elements, high rope elements, swimming, other water activities, and all indoor and outdoor events and activities. I understand all activities are optional and that my child or I have voluntarily applied to participate in the events and activities of the Camp. I understand the foregoing activities and all other events, hazards or exposures connected with the Camp and the indoor and/or outdoor activities, involve risk of harm and that accidents or illness can occur in places without medical facilities, physicians, or surgeons. I am aware of the risks and damages inherent with those activities and I knowingly and willingly assume the risk of injury. Medical Information Participant Name: Mailing Address: City: State: Zip: of Birth: Phone: Person to notify in case of an emergency: Phone number(s) of emergency contact person: Name of doctor and phone number: General Health Information: Do you currently have any of the following? 1. Recent serious injury: Y N 2. Recent surgery: Y N 3. Allergies to medications: Y N 4. Food Allergies: Y N 5. Asthma: Y N If yes to any of the above, please describe: 7. Do you take any medications regularly? Y N If so, please list here: (All medications must be in originally labeled containers) 8. If yes, will you have these with you? Y N 9. Your camper must have received all vaccinations required to enter school in the state of Texas in order to attend camp. Has your camper received all of these required vaccinations? Y N 10. of last Tetanus Shot 11. Add any other necessary medical information: (Attach separate sheet if needed) 12. I give permission for my camper to receive age appropriate over the counter medication. Y N Insurance Information: 1. Medical Insurance Company: 2. Plan or Group Number: 3. Insured Name: 4. Insured I.D. # or Member #: 5. Insurance Company Phone Number: 6. Insurance Company Address:

10 Authorization for Emergency Medical Treatment I have listed above my or my child s physical conditions or medical problems that may need attention and all medications regularly used by myself or said minor. I understand failure to disclose medical information/condition may result in dismissal from Carolina Creek Christian Camp. In case of the illness of myself or my child, Carolina Creek Christian Camp will try to notify whoever is listed as the emergency contact person. In the event there arises a medical emergency concerning myself or my child, at a time where the emergency contact cannot be notified, I authorize Carolina Creek Christian Camp to consent to any necessary X-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care. I hereby consent and give my permission to the Carolina Creek Christian Camp staff or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon myself or my child that may, in their sole discretion, be necessary and proper under the circumstances. General Release and Waiver of Liability I DO RELEASE, ACQUIT, DISCHARGE, AND COVENANT TO HOLD HARMLESS CAROLINA CREEK CHRISTIAN CAMP STAFF, PERSONNEL, OR ANY OF ITS REPRESENTATIVES FROM ANY ACTIONS, DAMAGES, OR LIABILITIES ARISING OUT OF ANY INJURIES OR PROPERTY DAMAGE SUSTAINED DURING THE PARTICIPATION IN THE CAMP AND/OR RESULTING FROM THE TREATMENT OF ANY ILLNESS, SICKNESS, OR ACCIDENT, INCURRED BY MYSELF OR MY CHILD DURING HIS/HER STAY AT CAROLINA CREEK CHRISTIAN CAMP. In consideration for being permitted to attend Carolina Creek Christian Camp and participate in the activities conducted by the Camp, I, on behalf of myself, my child, my legal representatives, heirs and assigns, do hereby release, waive, and forever discharge Carolina Creek Christian Camp and its officers, employees, volunteers, and agents, of and from any and all loss, damage, claim, demand, action or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident that may occur as a result of my or my child s participation in the camp activities or any activities in connection with the Carolina Creek Christian Camp, whether by negligence or not. I, personally, and on behalf of my child (if child is the camp participant), hereby give Carolina Creek Christian Camp permission to use my and/or my child s name, photograph, quotations and likeness in any advertisements or promotions performed in connection with the camp and agree that neither I nor my child shall be entitled to any compensation for such use. I agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that if any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. X Adult Participant or Parent/Guardian Signature Printed Name and Address of Signatory: : X