Spanglish2018

Registration Form

Friday, May 25- Monday, May 28,2018

MEMORIAL DAY WEEKEND/ CAMP COLBY

Please return this form to:

Hispanic/ Latino Ministries

Attn: Roxana Topete

PO BOX 6006

Pasadena, CA. 91102

For any questions, please contact:

Roxana Topete

Phone: 626-568-7357

Fax: 626-796-7297

Email:

** (ONE REGISTRATION FORM PER APPLICANT) **

-Please Circle One: Youth (Grades 9-12) Young Adult (Age 18-25) - Counselor in Training- Counselor - Design Team

*NAME OF PARTICIPANT:______*AGE: ______

*EMAIL: ______

*GENDER: MALE______FEMALE______OTHER______

*DATE OF BIRTH: ______*CHURCH: ______*DISTRICT: ______

*ADDRESS: ______

*CITY: ______*STATE: ______*ZIP CODE: ______

*HOME PHONE: ______*CELL PHONE: ______

*T-SHIRT SIZE: (CIRCLE ONE) SMALL MEDIUM LARGE XL XXL

*PARENT/ GUARDIAN*

*NAME: ______*RELATIONSHIP: ______

*ADDRESS: ______

*CITY: ______*STATE: ______*ZIP CODE: ______

*HOME PHONE: ______*CELL PHONE: ______

*EMAIL: ______

*EMERGENCY CONTACT*

*NAME: ______*RELATIONSHIP: ______

*HOME PHONE: ______*CELL PHONE: ______

SPANGLISH MEDICAL RELEASE FORM

PLEASE CIRCLE ONE:

  1. DOES THE CAMPER HAVE ANY ALLERGIES?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. DOES THE CAMPER REQUIRE AN EPIPEN OR INHALER?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. DOES THE CAMPER HAVE ANY DIETARY RESTRICTIONS?

YES / NO

IF CIRCLED YES, PLEASE EXPLAIN:

MEDICATIONS AND TREATMENTS

(CAMP NURSE WILL BE ADMINISTRATING ANY AND ALL MEDICATIONS)

  1. WILL THE CAMPER BE TAKING ANY MEDICATIONS WHILE AT CAMP?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. CAN WE ADMINISTER OVER-THE-COUNTER MEDICATIONS TO THE CAMPER AT CAMP?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. IS THERE ANYTHING THE CAMP NEEDS TO BE AWARE OF WHEN GIVING ANY OF THE APPROVED OVER-THE-COUNTER MEDICATIONS TO THE CAMPER?

*IF ANY OVER-THE-COUNTER MEDICATIONS ARE SENT TO CAMP WITH THE CAMPER, THEY MUST BE IN THE ORIGINAL PACKAGE.

  1. HAS THE CAMPER HAD ANY OPERATIONS IN THE LAST 6 MONTHS?

YES / NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. HAS THE CAMPER EVER BEEN HOSPITALIZED OR HAD A SERIOUS INJURY?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. HAS THE CAMPER BEEN EXPOSED TO ANY COMMUNICABLE DISEASES WITHIN THE LAST 3 MONTHS?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. DOES THE CAMPER HAVE ANY RESTRICTIONS ON ACTIVITY?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. WILL THE CAMPER REQUIRE ANY SPECIAL ASSISTANCE WHILE AT CAMP?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

  1. PLEASE LIST ANY OTHER MEDICAL INFORMATION THE CAMP SHOULD HAVE ABOUT THE CAMPER.
  1. IS THERE ANYTHING YOU WOULD LIKE TO DISCUSS WITH THE CAMP MEDICAL STAFF?

YES/ NO

IF CIRCLED YES, PLEASE EXPLAIN:

PERSONAL CAMPER INFORMATION:(ALL INFOMRATION IS KEPT CONFIDENTIAL)

  1. WHAT DO YOU HOPE TO GAIN FROM THIS EXPERIENCE?
  1. WHAT WOULD YOU LIKE TO LEARN ABOUT GOD/CHRISTIANITY/ CHURCH?
  1. WHY ARE YOU ATTENDING SPANGLISH?
  1. IS THERE SOMETHING YOU NEED HELP OR PRAYER FOR?

18. WHAT ARE YOUR TOP 3 LIKES?

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-

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19. TOP 3 DISLIKES?

-

-

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Medical Waiver & Adult Background Check

I hereby authorize pursuant to Family Code Sections 6900-6910 any adult staff member of Cal-Pac Camps, as agent for the undersigned to consent on behalf of said minor to medical care, including, X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, under the general or special supervision of, and upon the advice of or to be rendered by camp Health Services. a physician or surgeon licensed under the provisions for the Medical Practice Act. For myself, and on behalf of said minor, I release, hold harmless and indemnify the California-Pacific Annual Conference, its Boards, officers, members, clergy, staff, agents and volunteers from any and all claims, losses, costs, obligation and liabilities for injuries to any persons or for damages to or loss of property of any kind in any way arising out of participation of the above mentioned minor, whether or not arising from any alleged active negligence, fault or legal liability of any kind of the California-Pacific Annual Conference, its Boards, officers, members, clergy, staff, agents and volunteers to the fullest extent permitted by California law. This authorization shall be effective January 1st to December 31st, 2018 inclusive. A photocopy or other reproduction, including electronic agreement, of this authorization shall be considered as an original.

Adults ( Age 18 and older):

I also understand that as an adult participant (anyone aged 18 and older), on site with minor participants, that my name will be checked against the National Sex Offender's Public Website and I may be asked to not attend this event dependent upon the results of this check.

I further understand that as an adult Event/Design team staff (anyone aged 18 and older), I must submit to online Safe Gatherings training, which includes a full criminal background check every three (3) years per the Cal Pac Conference policies and may be asked to step down as staff, dependent upon the results of this training and background check.

*PLEASE SIGN:

Adult Camper (Ages: 18+)/ OR Parent or Guardian of Camper Printed Name_______

Adult Camper (Ages: 18+)/OR Parent or Guardian of Camper Signature ______

Youth Camper Printed Name (Ages: 14-17) ______

Youth Camper Signature (Ages: 14-17) ______