Special Ministries Camp at Whispering Hope Ranch

Special Ministries Camp at Whispering Hope Ranch

Best Friends Under the Big Top

Camper Registration

Registration Form (Pages 3 4)

Activity Participation Waiver (Pages 5 & 6)

Medication and Doses Sheet, if sending prescription medication (Pages 7, 8 & 9)

WHR Liability Release for Adults – if you are your own guardian

WHR Liability Release for Minors – must be filled out by legal guardian for student

WHR Photography Release – must be filled out by all campers

Camp Dates: September 22-24

Registration Due by September 17

Cost: $195

Check in: 12-12:30pm (bring a sack lunch)

Drop off: Scottsdale Bible Church, Room D103

Questions: Pascal Tulley

Office: 480.824.7257
Cell: 856.465.1190

Bus Returns: Sunday, September 24 at 3:30pm

Pick up: Scottsdale Bible Church, South Parking Lot

Packing List on Back

Packing List

Please put your name on ALL luggage and personal items

· Long Pants

· Long Sleeved Shirts

· Knee Length Shorts

· T‐Shirts

· Jacket or Warm Sweater (It will get COLD)

· Sturdy Closed‐Toe Shoes (If possible, two pair in the event one gets wet. Closed-toe shoes are required on the property.)

· Socks

· Under Garments

· Pajamas/Robe/Slippers

· Pillow

· Sleeping Bag or Twin Sheet Set and Blanket(s)

· Bath Towel(s) and Washcloth(s)

· Shampoo/Conditioner

· Soap

· Hairbrush/Hair Dryer

· Toothbrush/Toothpaste

· Sunscreen

· Other Personal Items

Other Useful Items:

· Refillable Water Bottle with Name

· Hat/Cap

· Flashlight

· Sunscreen

· Rain Gear/Umbrella

· Ear Plugs (for light sleepers!)

All prescription medication must in their original containers and turned into the camp nurse upon check-in.

Emergency Contact Numbers for Parents/Caregivers

Main Ranch Office (M-F 9am-4pm): 877.478.0339

Wellness Center Phone & Answering Machine: 928.478.0146

Registration from for Special Ministries Fall Camp 2017

Send Registration to: Scottsdale Bible Church/Special Ministry

7601 E. Shea Blvd.

Scottsdale, Arizona 85260

Camper Name:
First, Last
Age: / DOB: / T-shirt Size: S M L XL XXL XXXL
(circle one)
Street Address:
City: / State: / Zip Code:
Parent/Caregiver Email:
Cell Phone: / Home Phone:
Medical History:
Describe Medical Conditions
Does the camper take any medications? [ ] Yes [ ] No
If yes, please fill out MEDICATION AND DOSES for nurse. ONLY PRESCRIPTION MEDS & NECESSARY OVER THE COUNTER IN ORGINAL BOTTLES
Emergency Contact
Name of person to contact in case of Emergency if we can’t get a hold of parent/caregiver:
Name Relation Cell Phone

Are there other things you would like us to know?

The information you provide will help us care for your student.

Include bathroom needs, night time issues, seizures and precautions.

Please, alert us of any food allergies and/or restrictions regarding food.

______

Activity Participation Agreement

Activity Information

Name of sponsoring organization: Scottsdale Bible Church

Address: 7601 E. Shea Blvd Phone: 480.824.7200

Name of sponsor’s coordinator: Rae Larson Phone: 480.824.7267

Description of activity: Special Ministry Camp

Date(s) and location of activity: September 16-18, 2016 Whispering Hope Camp , Payson Arizona

Participant Information

(To be completed by adult participant or legal guardian)

Name of participant: ______

If minor, name of guardian:______

Address: ______ Phone: ______

Name of emergency contact: ______

Phone (daytime): ______Phone (evening): ______

Is sponsor authorized to approve medical treatment? □ Yes □ No

Is participant covered by personal/family medical insurance? □ Yes □ No

If yes, name of insurer: ______

Policy or group number: ______

Please list any allergies or special medical conditions we should be aware of: ______

______

Does participant requires prescription medications to be administered while at activity? □ Yes □ No

(If “Yes” checked above, complete Prescription Medication Authorization Form prior to participation in activity).

Activity Participation Agreement

In consideration for the opportunity to participate in the above activity, which constitutes good and valuable consideration, the Participant agrees to the following: The Participant (or parent/guardian on behalf of their child, if Participant is a minor) acknowledges and agrees to assume the risks of injury to themselves or their child associated with participation in, as well as transportation to and from, the activity, including, but not limited to physical injuries and permanent impairment or death The Participant (or parent/guardian) accepts personal financial responsibility for any injury sustained during the activity or during transportation to and from the activity. In addition, the Participant (or parent/guardian) expressly agrees to indemnify, defend, and hold harmless the activity sponsor, Scottsdale Bible Church, as well as their respective agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Sponsor”) from and against any alleged claims, damages, losses, expenses (including reasonable attorney’s fees and costs) and any injury related to, involved in, or arising out of, directly or indirectly, the described activity (or transportation to and from the activity), whether such injury is the result of the negligence of the Sponsor or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Sponsor cannot agree upon such a process, the parties agree that any dispute will be submitted to binding arbitration with a single arbitrator agreeable to the parties with relevant experience in the particular field of law. If there is an impasse between the parties in the selection of the arbitrator, the Institute for Christian Conciliation in Billings MT, shall be asked to provide the name of a qualified person that will serve in that capacity. In an effort to fully encourage and implement a biblically faithful process, Scottsdale Bible Church agrees to pay all fees and expenses, which may be required by the arbitrator. The arbitration shall be conducted in accordance with the “Rules of Procedure for Christian Conciliation”, contained in the Peacemaker Ministries booklet, Guidelines for Christian Conciliation (“Rules”), to the extent any of the Rules are not prohibited by law. If any of the Rules are prohibited by law, then such rules shall not be applied and the arbitrator shall apply the applicable provision of law in place of any such prohibited provision of the Rules. The parties further agree that the above alternative dispute resolution process and arbitration procedure will be the exclusive means of redress for any disputes relating to or arising from this agreement or participant’s participation in the activity. THE PARTIES AGREE TO EXPRESSLY WAIVE THE RIGHT TO A JURY TRIAL. The parties acknowledge by waiving their rights to file a lawsuit to resolve any dispute between them, they are not waiving their right to employ legal counsel at their own expense to assist them in any phase of the process. The arbitrator's award shall be final and binding on the parties provided that any award shall be reviewable by a court of law to the extent allowed by and in conformance with the law, including for any error of law by the arbitrator. The parties may resort to the Superior Court of Arizona for enforcement thereof. The clauses in this agreement are severable. If any clause, or portion thereof, shall be found to be invalid or unenforceable, that shall not affect the validity of the other clauses or portions thereof herein.

I have read, understand and voluntarily agree to the terms and conditions herein:

Signature: ______Date: ______

(Participant or parent/guardian if participant is a minor)

PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

Scottsdale Bible Church - Special Ministries 2015

I hereby give the SBC camp volunteer registered nurse permission to administer the following products according to manufacturer’s instructions or as otherwise specified. I trust the volunteer registered nurse to use his/her best judgment as situations arise. If there is any doubt, he/she can call for verification. Food allergies will be listed below.

Please check YES or NO for the medications listed below.

YES NO Specifications

q q Ibuprofen ______

q q Insect repellant ______

q q Cold Medicine ______

q q Rash ointment ______

q q Tylenol ______

q q Antiseptic ointment

q q Band-aids

q q Anti-itch cream

q q Hydrogen peroxide

q q Cough syrup

q q Cough drops

q q Decongestant

q q Antihistamine

q q Ipecac syrup

q q Pepto Bismol

q q Other ______

Camper’s Name (please print): ______

Parent/Caregiver Signature: ______

Phone numbers: (Home) ______(Cell) ______

MEDICATION AND DOSES LIST

ALL medications MUST be sent in original prescription bottles.

**FILL OUT A FORM FOR EVERY MEDICATION INCLUDING OVER THE COUNTER MEDS

------

MEDICATION: ______DOSE: ______

INSTRUCTIONS: ______