Forms Must Be Filled out Completely! AGES 8-12

YOUTH EXTRAVAGANZA 2015JRCAMPER REGISTRATION

Forms must be filled out completely! AGES 8-12

First Name______Middle______Last Name ______o male o femaleHome Address ______City ______County ______State_____ Zip______Age_____ Birth Date ______Fathers First Name ______Fathers Last Name ______Mothers First Name ______Mothers Last Name ______This camper lives with o both parents o father o mother o other Legal Guardian Name______other explain ______Home Phone Number______e-mail ______Fathers Cell Number______Fathers Work Number______Mothers Cell Number ______Mothers Work Number ______Name of Family Physician ______Phone Number ______Do you carry family medical/hospital insurance o yes o no Do you have Sooner Care, AR kids or an Indian Card O yes O no If you answered yes,circle the appropriate program. Is this camper Cherokee? o yes o no Carrier Name ______Phone Number ______Group Policy Number ______Name of Policy Holder ______In case of emergency Youth Extravaganza will contact you immediately. If we are unable to reach you please list a secondary contact person whom we can call. This person must not be someone living in the same household, otherwise your group leader will automatically be the designated contact person.Name______Day Phone ______Relationship ______Evening Phone ______Medical Insurance Name of Family Physician ______Phone Number ______Do you carry family medical/hospital insurance o yes o no Carrier Name ______Phone Number ______Group Policy Number ______Name of Policy Holder ______Immunizations: ______tetanus ____polio booster _____measles ______mumps Past Medical History (check box to give appropriate information.) ____asthma _____ sinusitis ______bronchitis ______kidney trouble ______diabetes ____ heart trouble dizziness ______stomach upset ______hay fever ______other List other ______Allergies: Food ______Penicillin or other drug (name) ______Insect stings/bites______Poison sumac, oak, or ivy ______Previous operation or serious illness ______Any current medications (list) ______Special Diet (Name) ______Childhood Diseases: _____ chickenpox _____ measles _____mumps _____ whooping cough Other List______This form must be signed by camper's legal guardian.

Group Information This camper is registering as o as a church group o individual Who will be picking up the camper ______Church Group Name ______Church Phone ______Senior Pastor's Name ______Group Leaders Name______This form must be signed by camper's legal guardian As the campers parent or legal guardian I authorize camper to attend camp and engage in all camp activities, strenuous activities, including water sports, football, baseball, basketball, and volleyball. I agree personally and on behalf of the minor to relieve Youth Extravaganza, (Victory Worship Center collectively)(Youth Extravaganza Collectively) and its staff as well as all private and public venues that will be used in coordination with this camp from all liability for harm of Minor and Minor's possessions resulting directly or indirectly from minor's participation in camp even if New Vision or it's related parties are negligent, and to indemnify New Vision and all associated parties against any such liability. I authorize administration of a tetanus shot or other medical treatment deemed necessary by Youth Extravaganza and I agree to release and indemnify Youth Extravaganza and all related parties against all liability and cost for treatment. I also authorize Youth Extravaganza and its related parties to use photos or video tapes for promotional uses as well as for record keeping purposes. I authorize my child to walk cross the street and be transported to events and venues.

I am the Parent or legal guardian of the minor listed above and declares that all information is correct. Date ______Printed Name______Signature______If your child has a blue card from the Cherokee Nation please include a copy.