Registration Fees

Chartered Outposts$ 45.00

Non-Chartered Outposts$ 50.00

Pastors as GuestsNo Charge

Please Note: There will be NO events organized for RK’s.Ranger Kids are welcome to visit as guests as long as they are accompanied by a parent or guardian.

NORTHERN NEW ENGLAND DISTRICT COUNCIL ASSEMBLIES OF GOD
ACTIVITY SUPERVISORY CERTIFICATION FORM

EMERGENCY MEDICAL FORM /PERMISSION SLIP / BOY

POW WOW 2016August 26, 27, and 28

Name:______

Birth Date:____/____/____Age:______Grade:______

Address:______

City/Town:______State:______ZIP______

Both Parents Names:______

Doctor:______Phone:______

Health Insurance Company/Policy#:______

*****************************************************************************************

HEALTH HISTORY

HAS HE HAD THE FOLLOWING:

An attack of appendicitisYes No

Severe AllergiesYes No

Asthma or hay feverYes No

Diabetes and/or InsulinYes No

Hernia (rupture)Yes No

Rheumatic feverYes No

Scarlet feverYes No

IS HE/SHE UNDER MEDICAL CARE WITH MEDICATION

Reaction to bee stingsYes No

Significant disease, injury/operation:Yes No

Is his activity restricted medicallyYes No

Other Necessary Medical Information

______

______

**************************************************************************************

PERMISSION FOR EMERGENCY MEDICAL TREATMENT

In the event:______becomes ill or sustains injury while in the care of or under the

supervision of activity leaders, they are given permission to administer first aid for his relief. Consent is

hereby given to admit him to any hospital; consent is also given to any licensed physician and or

surgeon called, or to whom our son is taken for treatment by them to administer such treatment, drugs

and medicines, and to perform such medical/surgical procedures as he shall deem the existing

emergency requires for relief of pain and to preserve his life and health. I hereby agree to reimburse

any and all persons and/or facilities for any expenses incurred in the care of my son, should medical

treatment be necessary.

I also give my son permission to go to the NNED DISTRICT POW WOW Camping Tripin Belgrade,

Maineon August 26, 27, and 28, 2016.

Date: ______Signature: ______

Parent/Guardian

Phone number where you may be reached in case of emergency during the above dates:

(______)______

EMERGENCY MEDICAL FORM / ADULT

POW WOW 2016August26, 27, and 28

Name:______

Birth Date:____/____/____Age:______

Address:______

City/Town:______State:______ZIP______

Name of closest relative:______Relationship______

Doctor:______Phone:______

Health Insurance Company/Policy#:______

*****************************************************************************************

HEALTH HISTORY

HAS HE/SHE HAD THE FOLLOWING:

An attack of appendicitisYes No

Severe AllergiesYes No

Asthma or hay feverYes No

Diabetes and/or InsulinYes No

Hernia (rupture)Yes No

Rheumatic feverYes No

Scarlet feverYes No

IS HE/SHE UNDER MEDICAL CARE WITH MEDICATION

Reaction to bee stings Yes No

Significant disease, injury/operation: Yes No

Is his/her activity restricted medicallyYes No

Other Necessary Medical Information

______

______

**************************************************************************************

PERMISSION FOR EMERGENCY MEDICAL TREATMENT

In the event:______becomes ill or sustains injury while in the care of or under the supervision of activity leaders, they are given permission to administer first aid for his/her relief. Consent is hereby given to admit him/her to any hospital; consent is also given to any licensed physician and or surgeon called, or to whom he/she is taken for treatment by them, to administer such treatment, drugs and medicines, and to perform such medical/surgical procedures as they shall deem the existing emergency requires for relief of pain and to preserve his/her life and health. I hereby agree to reimburse any and all persons and/or facilities for any expenses incurred, should medical treatment be necessary.

Date: ______Signature: ______

Phone number where closest relative may be reached in case of emergency:

(______)______

ACTIVITY SUPERVISORY CERTIFICATION FORM
This form is to be completed for all persons involved in the supervision or custody of minors while
attending any District activity involving children and youth. It is being used to help the District provide a safe
and secure environment for those children and youth who participate in our District sponsored program.
PLEASE PRINT CLEARLY:
Name of District Event: / Summer POW WOW / Date: / August 26-28, 2016
Church Name:
Address:
City: / State: / Zip:
Phone:
Person in charge of group at this district event:
List full name of all persons who will be attending this event in a supervisory or custodial capacity:
1. / 6.
2. / 7.
3. / 8.
4. / 9.
5. / 10.
Does your church have a written child abuse policy on file? / Yes ______NO ______
PASTOR'S CERTIFICATION OF CHURCH WORKER(S):
I am personally acquainted with the above named person(s), and in my opinion is/are competent and
qualified for work with minors. I know of no facts or allegations that raise any question concerning suitability
for working with minors in the above stated District activity. Those named above have completed a
screening application that is on file with this church.
Pastor's Signature of Affirmation* ______
* Participation in this district event will be denied
for those acting in a supervisory/custodial capacity if not signed by the Pastor.

T-Shirt Order Form 2016

Outpost #______

ORDER:

QuantitySizeEachTotal

______S $10.00 ______

______M $10.00 ______

______L $10.00 ______

______XL $10.00 ______

______XXL $12.00 ______

______XXXL $12.00 ______

Total Order

Signed:______

Note:All T-Shirts must be paid for at the time of placing your order.
T-Shirts will be available when you register at POW WOW

Your Order is due no later than August 5th.

Mail to: District DirectorTim Haynes, 5 Fletcher Road, Anson, ME 04911
Questions? Please call District Director Tim Haynes at 207.399.3612

Email:

Required for all Royal Rangers under 18 years of age participating in Water Tubing at Pow Wow 2016

Name of Royal Ranger:
______

Age:______Outpost # ______Commander: ______

Name of Parent or Legal Guardian (Print)

I hereby give permission for my son to participate in the “Water Tubing” atPow Wow, August 26-28,2016

I hereby attest that I am personally allowing my son to participate in Water Tubing, and assume sole responsibility for any personal injury. I will not hold the Northern New England District Royal Ranger ministry or any of its leader’s responsible. In the event of personal injury, I understand the Royal Ranger leader in charge will comply with all reporting requirements required by Maine Laws.

The leader in charge will exercise all precautions in this event. This event is for the boys to have fun and not to get injured. Safety is of utmost importance and the safety of you boy is our main concern.

______

Signature of parent or legal guardian Date

Telephone Number:______