Originally from South Korea, Pete hails from the suburbs outside of Washington, D.C. He moved to Vancouver in the summer of 2008 to attend Regent College and started ministry with youth at Surrey Presbyterian Church. He had the privilege of marrying his lovely wife Christina in May 2009 and welcoming two boys, Mason and then Connor into the world. He now serves as the youth pastor of Korean Central Presbyterian Church of Houston, where he began in April 2013. Most recently, the newest addition to the family, Kara arrived in Feb. 2015! Pete s passions are both vast and intense being an authentic Christian for Jesus in today s world by living the life Jesus gives, loving his wife Christina and his sons, cheering sports of all kinds (both as a participant and as a fan), especially basketball and football, especially the Dallas Cowboys, FOOD (finding, eating, creating and sharing), and good music (old school R&B, Jason Mraz, Shane and Shane, GOOD hip-hop). Mac Shirley is a native of Arlington, Texas. He holds a Master of Arts in Ministry Communication from Dallas Baptist University. Mac JUNIOR HIGH: married his high school BO DUSTER sweetheart, Liseth, and they live in Arlington with their dog, Harley. Mac serves the students and parents at Pantego Bible Church as Student Pastor with contagious enthusiasm and love for God's Word. He also serves at the Director of Events with Youth World, an urban ministry in Dallas founded by his grandfather. When he's not teaching or building relationships with students, he loves riding motorcycles, being out on the lake, and playing Spikeball, and of course taking his beautiful wife on dates in his awesome Jeep. At DCCYC students will experience authentic worship and relevant Biblical teaching for the everyday adventure of following Jesus who alone is our all in all. Additional focus workshops make learning truly interactive: Gospel: how to rescue. Affections: love at work.. Prayer: a walk with Jesus. Related: a place to belong. Disciplines: brokenness aside. Apologetics: systematic defense. Justice: working results. Holiness: where your best prayers take you. In addition to these learning experiences, they will enjoy fun fellowship and recreational games and creative activities. They will experience teamwork and community as they engage and interact with other students and adult counselors. Dallas Chinese Christian Youth Camp June 17-21 "Lord, You have made us for Yourself, and our hearts are restless until they find rest in You." {Augustine} Early bird registration by May 10th $290
Please submit this side to your church Keep this side Personal Information: Please fill in this form fully and legibly (please print). Also attach Lakeview Baptist Assembly Medical Authorization Form & DCCYC Medical Release Form. Full name: M F Grade in FALL2015: D.O.B. / / (mm/dd/yy) Address: City: State: Zip: E-mail: Parents: Phone: ( ) - Home church: REGISTRATION FEE REFUND AND DEADLINES POLICY BY MAY 10 th $ 290 BY MAY 31 st AFTER MAY 31 st $ 315 $ 340 BY MAY 10 th FULL BY JUNE 7 th HALF AFTER JUNE 7 th NO REFUND Your departure location: ACC CCCFC NLGC My Christian Walk No / Yes: [S M L XL] I have trusted Jesus as my Savior [Yes / No] I attend church regularly [Yes / No] I have been baptized [Yes / No] If No, I m thinking about getting baptized [Yes / No] How often do you pray? Never 1 2 3 4 5 Always How often do you have devotionals? 1 2 3 4 5 How is your spiritual walk? (5 being best)1 2 3 4 5 I currently serve at church [Yes / No] If No, I would like to serve in the area of Camp Discipline: 2 strikes policy For example, if a camper fails to stay in his/her assigned cabin between 11:30 pm 7:00 am, then: (1) 1st offense: $100 fine and parents will be notified immediately. (2) 2nd offense: (or on the last day of camp) $200 fine and parents will be called to take camper home. Campers will not be allowed to return to future camps unless fines are paid. My Commitment to Honor God at Camp: In submitting this DCCYC summer camp registration, I am agreeing to abide by the rules and regulations set by DCCYC Camp Board and Lakeview Baptist Assembly. I accept the penalties/fees and discipline that come as consequences of failing to follow the rules. Youth Sign Date: Parent Sign Date: RETURN your filled forms & your CHECK (payable to DCCYC) to your youth leader. DO NOT send your check to Lakeview Baptist Assembly. What to Bring to Camp: Bible Friends Sleeping Bag Toiletries Towels Clothes Swim/Sports wear Sunscreen & Insect repellant Notebooks Pen/pencil Flash light Alarm clock Medicine if needed Money for snacks/souvenirs Light jacket Both medical forms What Not to Bring to Camp: Tobacco, Drugs, Alcohol, and Weapons If found, local authorities will be contacted. MP3 players, CD player, video games, video players, ipod, itouch, Laptop, etc. Due to fire ant problems, Lakeview Baptist Assembly does not allow any food in the cabins. Please leave all snacks at home. We will inspect cabins and take away food. Dress Code: To avoid causing unnecessary temptation and distraction, please dress appropriately for a Christian camp. That means wearing shorts that are modest (not too short or tight). All shirts must overlap the waist and not be too tight fitting. Exposed midriffs will not be allowed. SLEEVELESS SHIRTS are NOT permitted, unless they are covered by a shirt. Yoga pants and leggings must be covered by shorts. Swim wear for guys are board short swim trunks and for gals are lined or non-translucent one-piece swim wear; no bikinis. If you are wearing something inappropriate, counselors will ask you to change into something more appropriate. Lakeview Baptist Assembly is located at: 240 Camp Circle Lone Star, TX 75668 Come to Lone Star via HWY 259. Go to Lone Star Baptist Church sign, turn west on Williamsburg Street, go 3 blocks to Stop sign. Go straight ahead, through Lone Star Baptist Church parking lot. Lakeview is located behind Lone Star Baptist Church. CHARTER BUS INFO: Departure: June 17 th Arlington Chinese Church: 9:00AM New Life Gospel Church: 9:30AM Collin County Chinese Fellowship Church: 10:00AM Returning: June 21 st Arlington Chinese Church: 6:00PM New Life Gospel Church: 5:30PM Collin County Chinese Fellowship Church: 5:00PM (Please remember to bring a sack lunch for bus ride on June 17)
MEDICAL RELEASE FORM Dallas Chinese Christian Youth Camp As the parent/legal guardian of (Name of Student): I hereby give my permission for my child to participate in the Dallas Chinese Christian Youth Camp or DCCYC, or any of DCCYC s activities. I hereby release DCCYC, its staff, sponsors and officers from liability for any illness, injury, misadventure, or harm of any kind suffered as a result of participation in DCCYC. I request that in my absence the above-named student be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named student. Date of student s birth: / / Date of last Tetanus Booster: / / Allergies: Other Medical Conditions: Student s Physician: Phone #: ( ) - ( ) - Medical Insurance Co. Phone #: Policy Holder Policy Number Name of Parent/Guardian: Street Address: City: State: Zip Phone # H: ( ) - Phone # M: ( ) - Work #: ( ) - Person to notify if parent/guardian is unavailable: Street Address: City: State: Zip Phone # H: ( ) - Phone # M: ( ) - Work #: ( ) - Signature of Parent /Guardian: Date: \ DCCYC REVISED 04/15
Dear Parents of 2015 DCCYC Campers: Let me be one of the first to welcome your child(ren) to DCCYC 2015! We are excited that you would allow your child the opportunity to grow with us in Christ on this 5-day venture to know God as our all in all. As the continuing DCCYC Camp Nurse, I have a few registration points I would like to highlight to ensure that I am able to provide the best possible care for your children: 1) If your child has health/medical insurance coverage, please remember to list the Policy# AND Group# 2) Please complete your child s medical history, INCLUDING: *Allergies to Food & Medication (List None, if No allergies) *Date of Last Tetanus Shot 3) Complete AND sign the Medication Release/Administration Form (Back page of the Medical Information/Consent/Agreement to Participate Form) * Medications MUST be brought in their ORIGINAL containers! Medications found otherwise (i.e. plastic/ziplock bags) will not be accepted! 4) ALL medications MUST be given to the Camp Nurse. (Exceptions will be made by the Camp Nurse on a case by case basis.) 5) Please DO NOT bring the following medications as we will have them on-site: *Tylenol/Acetaminophen *Ibuprofen/Motrin/Advil/Midol *Benadryl/Diphenhydramine *Zyrtec/Cetrizine (Note: This medication MUST be listed on the Medication Release/Administration Form in order for me to administer!) *Claritin/Loratadine (Note: This medication MUST be listed on the Medication Release/Administration Form in order for me to administer!) Thank you so much for your help! If you have any questions or concerns, please notify your Youth Pastor/leader, and they will get in contact with me. I look forward to serving your children at DCCYC 2015! Sincerely, H. Charlie Lin, RN, BSN, FCN, ICPFE
Lakeview Baptist Assembly P. O. Box 0130 Lone Star, Texas Phone 903-656-3871 Medical Information/Consent/Agreement to Participate Church/Organization: Participant s Last Name: First Name: Date of Birth: Age: Sex: Address: Social Security Number: (Number & Street) (City & Zip Code) Parent/Guardian: Address: Relationship: (If different than participant s) Daytime Phone: Cell Phone: Pager Emergency Notification Name: Relationship: Daytime Phone: Evening Phone: Cell Phone: Pager: Medical Dr. Name: Phone: Dentist Name: Phone: Insurance Company: Name of Insured: Policy # Insurance Address: Phone Number: Sponsor allowed authorizing emergency care in lieu of Parent/Guardian: Person permitted to take Participant from camp: Please include any other information you think we need to know on an extra sheet of paper. Medical Information Grade Completed: Allergies (List and Explain Reaction): Check any conditions: Diabetes Epilepsy Asthma Heart Chest Pain Thyroid Kidney Dizziness Back pain Broken Bones Bleeding Disorders Operations High Blood Pressure Any Other Conditions Explanation of the above: List Any dietary or Physical Restrictions on back: Are all immunizations current: Yes No Date of Last Tetanus Shot: List Medications currently being taken: I/we hereby authorize the camp nurse or camp director to administer all medication brought by participant. If a medical emergency should arise while the above listed camper is in attendance at Lakeview Baptist Assembly, I/we hereby authorize the camp nurse or camp director to provide care to the camper and/or transport the camper to a medical facility. I/we further authorize the health care provider of the medical facility to administer necessary medical and/or surgical care upon arrival at the medical facility. I/we understand that camp officials will make a conscientious effort to locate the parent/guardian or the emergency contact listed on this document before any action will be taken. If it is not possible to locate the emergency contact listed, I/we will accept the expense of emergency medical and/or surgical treatment. I/we give my authority and consent for Lakeview Baptist Assembly or camp nurse to treat my child for minor injuries and illnesses with the appropriate nonprescription medication. AGREEMENT TO PARTICIPATE: ASSUMPTION OF RISK AND RELEASE OF LIABILITY WHEREAS, THE UNDERSIGNED ( the PARTICIPANT ) wishes to be accepted for participation in all activities conducted by LAKEVIEW BAPTIST ASSEMBLY & CONFERENCE CENTER, INC. In consideration of, and for the right to participate in such an activity by LAKEVIEW BAPTIST ASSEMBLY & CONFERENCE CENTER, INC., its Directors, Officers, Trustees, Employees, Agents, and/or Associates, I/we have and do hereby assume all of the risks and any other ordinary risk incidental to the nature of the activity. Further, I/we will hold them harmless from any and all liability, actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss, medical bills, hospital bills, and doctor bills, or other wise, which the participant now has or which may arise from or in connection with participation in any other activities arranged for me by LAKEVIEW BAPTIST ASSEMBLY & CONFERENCE CENTER, INC., its Directors, Officers, Trustees, Employees, Agents, and/or Associates, and their heirs, executors, and administrators, successors and assigns and for all members of my family, including any minors accompanying me. I/we fully understand that my physical activity involves risk of injury. I/we also understand that my participation in any activity is entirely VOLUNTARY. I/we enter into this activity and take full responsibility for the decision to participate or not to participate and agree to follow all safety instructions. AGREEMENT TO HAVE PHOTOGRAPH TAKEN: I/we are aware of the fact that photos of my child or of myself may be taken during the week by camp staff, which may appear in future camp publicity. By signing this, I/we give permission to use these photos, aware of the fact that my child or myself WILL NOT be identified by name in any such photos. I/we hereby give permission to have my photograph taken. If this is unacceptable, I/we will so state that fact here by writing NO in the space provided. Signature of parent/guardian (if participant under age 18) Date of Signature Signature of participant Date of Signature FOR ADULT SPONSORS ONLY (What is your responsibility while attending camp?) Pastor/Staff Recommendation: I recommend this adult to be a responsible sponsor. (sponsor, camp director, recreational team) Pastor/Staff Signature
Lakeview Baptist Assembly Camps-Conferences-Retreats Medication Release/Administration Form Lakeview requires that all sponsors/campers who need medication during their attendance at camp must do the following: 1. Complete and present the consent below, signed by parent or legal guardian for administration of medication while the student attends camp at Lakeview. 2. Bring the medication IN THE ORIGINAL BOTTLE (prescription or over-the-counter), properly labeled as prescribed by law. 3. Present this form and the medication indicated on this form to the nurse upon arrival on campus and abide by his/her instructions for administration. 4. If more than one medication is to be administered, a separate form is to be completed and signed for each medication. Name: Medication Information for: Birth date: Sex: M F (Month/Day/Year) Church group student came with (Church Name) (Church City & State) 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: As the parent or legal guardian of the above child, I hereby give permission for the camp nurse or administration to administer this medication to my child. ( ) - ( ) - Parent/Guardian signature Daytime Phone # (include area code) Evening Phone # (include area code) Date FOR OFFICE USE ONLY Please indicate at the left, time and your initials Day Date Time Given/ Person Administering each time medication is administered. Each person Dose 1 Dose 2 Dose 3 Dose 4 administering medication should indicate full Sunday name and title in space below. Monday Tuesday Wednesday Thursday Friday Saturday Notes or comments: