Camper Application

Daniell Baptist Association Summer Camp 2016

Adrian Camp & Conference Center

July 11-15, 2016 Ages 8-14

Cost - $190.00 if paid on or beforeJUNE 10, 2016

$210.00 if paid AFTER June 10, 2016.

Please complete and mail:

  1. Application (this page)
  2. NOTARIZED Medical Release From
  3. $50.00 deposit (checks made payable to DBA Summer Camp with balance of $140 if paid by June 10 or $160 dueby June 30)to:

Denise Pournelle

P.O. Box 4

Soperton, GA 30457

Applications will only be received by mail and only if Medical Release Form is notarized!

Deadline for application and FINAL PAYMENT is June 30, 2016

Boy ______Girl ______Age: ______Birth Date: ______/______/ ______

Name: ______Home Phone: _____ /_____ / ______

Church: ______Email Address______

MAILING Address: ______

City ______State______Zip Code______

T-Shirt Size (circle one) ADULT: S M L XL 2XL 3XL YOUTH: S M L

PLEASE NOTE: Campers will be placed in cabins according to age.

My child, ______, has my permission to attend the DBA Summer Camp, to participate in all camp activities, and to appear in camp photos/videos.

Person(s), other than myself, who are allowed to pick my child up from camp:

______

Parent's Name (please print): ______

Parent's Signature: ______Date: ___ / ___ / _____

Parent’s Cell Phone: ______/______/______Work ______/______/______

Please e-mail questions to

DBA Children’s 2016 Medical Release Form

(One form per participant and please complete in pen)

Legal Name: ______Birthdate: ___/___/_____ Gender: _____

Complete Home Address: ______

Home Phone: ______Cell phone: ______

Email: ______

EMERGENCY CONTACT INFORMATION:

Emergency Contact Name: ______Home Phone: ______

Cell Phone: ______Work Phone: ______

Relationship to participant: ______

MEDICAL INFORMATION:

Primary Physician: ______Phone #: ______

Insurance Company: ______Policy #: ______

Name of person insurance is under: ______Group #: ______Blood Type______(if known)

HEALTH HISTORY:

Do you have any physical limitations that would hinder your ability to participate in vigorous activities? If so, please explain. ______

Do you have any medical problems? If so, please explain. ______Are you allergic to any medications or food? If so, please explain. ______Describe your present physical fitness (e.g. for walking, manual labor, heavy lifting, carrying luggage). ______Do you take any medication on a regular basis? If so, please list: ______

CONSENT FOR EMERGENCY TREATMENT (Signature required from participant, or parent or guardian if under 18)

Note: If you should require medical attention while on an activity with Daniell Baptist Association (or one of its partners) for injuries received or illness contracted prior to coming, please provide trip coordinators with information necessary to give proper medical service during the trip.

In case of an emergency, I hereby give permission to the physician selected by the church/group sponsor representative to hospitalize, secure proper treatment for and order injections, anesthesia, or surgery for myself/my child (ward) as named above. I also hereby give permission for my child to participate in all activities, travel, service projects, and other activities.

I, therefore, agree to assume as an explicit condition of my/my child’s (ward’s) participation, any and all risks, including, but not limited to these enumerated above. I agree to hold harmless the above named sponsor, the sponsoring church or group from any and all liabilities, claims, demands, and causes of action whatsoever which may arise due to the participation of myself or my child (ward).

I realize, also, that in the event of illness or injury while participating in its activities, medical treatment may be required. I hereby give permission for any such treatment to be rendered, and I agree to bear the cost of such treatment.

Participant (or Parent/Guardian) Signature: ______Date: ______

______Date ______

Notary Public Stamp