2015Expedition Saturday Day Camp Registration Form

Child’s Information (Please print) Male / Female (Please circle)

Name Last:______First:__Grade:

Parent/Guardian Information

Mother/Guardian Name:

Mailing Address:______City: State:Zip:

Phone Home:Work:Cell:

E-Mail:

Father/Guardian Name:

Mailing Address:______City: State:Zip:

Phone Home:Work:Cell:

E-Mail:

Emergency Contact Information

(Must be an adult over 18 years old) If parent/guardian cannot be contacted in an emergency, please contact:

Name: ______Cell: ______

Relationship to Camper:______

Medical Information

Primary Care Physician:Phone:

Family Dentist:Phone:

Allergies: Check All That Apply

____Hay Fever____Penicillin____BeeSting____Insect BitePoison Ivy____Sunlight____Animal____Other:______

Food Allergies:

Known Conditions: Check All That Apply

____ADD___ADHD____Asthma____Epilepsy____Diabetes____Heart Problems_Autism____Headaches____Other:______

Special Needs: ______

Medications: Type(s)___Reason for Using Medication______

Do you give permission for day camp staff to administer the above medication? YN

Do you give permission for day camp staff to administer these medications? __Tylenol __Benadryl __Advil __Motrin __Ibuprofen

Insurance Information

Provider:Policy:

Expedition Day Camp has permission to provide and seek medical services as the first aid providers and other medical personnel deem appropriate. Y N

Day Camp Information

Are there activities that your child should be restricted from? If so, please explain.______

YOU CAN MAKE PAYMENTS AT THE MINISTRIES OFFICE DURING BUSINESS HOURS.

YOU CAN ALSO CALL VONIE AT 619-473-8879 ext 106 TO MAKE PAYMENTS.

Names of person who have permission for pick up from day camp:

(Persons must be listed or we won’t release your child)

Name: ___Cell:______

Statement of Responsibility for Camper

I promise to participate in the day camp activities with enthusiasm, trying my best to model the attitude of Jesus Christ (Philippians 2:5). I promise to obey the rules, which the camp has made for the best interest and safety for all including no violent behavior, no foul language, no disrespect to day camp staff, and no alcohol, drugs, tobacco, weapons of any kind, cell phones, iPods, MP3 players, or other electronic devices.

Signature of CamperDate:

Statement of Parent/Guardian

In signing this registration form, I hereby certify that the information is correct. I have read and understand the information page and the daily schedule provided.

I will abide by the refund policy of the day camp and I agree to pick up my child early in the case of illness or disciplinary reasons.

I give permission for my child to participate in the activities of Expedition Saturday Day Camp at the PVBCC recognizing that there is an element of risk in any activity that is outdoors.

I give permission for the use of photographs and video including my child to be used in publicity for the PVBCC newsletter, advertisements, and Internet websites reporting on Expedition.

I understand that the information in this form is confidential and will only be seen by the parent/guardian of this camper and the Expedition Day Camp staff of the PVBCC.

Payment and Cancellation Policy

  • We require that payments be made a week ahead to ensure adequate staffing / You may pay by credit card at the Ministriesoffice or call Vonie at 619-473-8879 ext 106
  • To receive a refund or credit, we require 24 hr. notice of cancellation / Ifcancellation is made with a week’s notice we will provide a full refund, if less than a week we will offer a credit.

Signature of Parent/GuardianDate:

RELEASE OF LIABILITY FORM (MINORS)

PINE VALLEY BIBLE CAMP AND CONFERENCE CENTER hereinafter referred to as “PVBCC” requires a signature for all attendees of the Camp. Furthermore this form releases PVBCC to photograph and/or use photographs of attendees for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and activities of PVBCC. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to attend PVBCC and to participate in any PVBCC activity.

IN CONSIDERATION of attending PVBCC, I acknowledge, appreciate, and agree that:

  1. Attendance and Activities at PVBCC may including but are not limited to basketball, swimming, strenuous competition games, paint ball, ropes course, giant swing, night games, frisbee golf, walking, hiking, volleyball, and other Summer/Winter related sports and activities. I realize that unanticipated and unexpected dangers may arise during and associated with the above activities. I voluntarily agree to accept any and all risks of injury, death or damages of any nature resulting directly or indirectly from participation in these activities.
  2. I understand that attendance at PVBCC and participation in any PVBCC activities can be physically and mentally intense. I understand the rules of play and will comply with all rules and regulations. If I observe any unusual or unnecessary hazard during my participation, I will bring such to the attention of the nearest official as soon as practical; and,
  3. I, for myself and on behalf of my heirs, assigns, personal representative and next of kin, HEREBY RELEASE AND HOLD HARMLESS PINE VALLEY BIBLE CONFERENCE CENTER, their officers, officials, agents and/or employees (“releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss of damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEE OR OTHERWISE, except that which is the result of gross negligence and/or wonton misconduct.
  4. I understand and agree that this Release of Liability Agreement covers attendance and each and every activity and event in which I participate hereafter.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNNG IT, AND SIGN IT FREELY AND VOLUNTARIALY WITHOUT ANY INDUCEMENT.

This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree not only to his/her release of Pine Valley Bible Conference Center and all other releases but also to release and indemnify the Releases from any and all liabilities incident to his/her involvement in these programs for myself, my heirs, assigns and next of kin.

X______Date Signed ___/___/___ Relationship to Participant______