SUMMER CAMP 2010
REGISTRATION CHECK LIST
- _____ Registration/Payment Form
(with payment attached)
- _____ Camper Profile (with picture)
- _____ Camper Covenant (with both Parent and
Child’s signatures)
- _____ Medical Release Form(completed and
signed)
- _____ Copy of Insurance Card (front and back)
- _____ Carolina Creek Medical Waiver
REMEMBER!!!
ALL COMPLETEDFORMS MUST BE TURNED IN TOGETHER WITH PAYMENT FOR YOUR CHILD TO BEREGISTERED FOR SUMMER CAMP 2010 .
PLEASE ATTACH RECENT PHOTO HERE
(no larger than 3 1/2 x 5)
Camper’s Name (preferred name for nametag)
______
first last
Boy ______Girl ______Date of Birth ______/______/______
Grade completed as of June ’10: _____
School ______
Member of SecondBaptistChurch? ______yes ______no
If yes, please circle which campus you attend: Woodway West North South Cypress
If no, do you attend another church? _____yes _____no
If yes, where do you attend? ______
Mom’s Name______Dad’s Name______
Is camper living with both parents? Y / N If no, with whom?______
E-mail Address of Parent(s) {used for camp updates, reminders}: ______
Activities your child is interested in:______
Has your child made a public profession of faith in Christ? ______
If yes, when and where? ______
Is your child apprehensive about spending time away from home? ______
Name only one friend that your child would like to have in their cabin: ______
Please describe any special home situation that we need to know: ______
______
______
Please list all medications your child takes regularly: ______
______
______
Please let us know of any special needs, limitations or fears your child may have:
______
______
______
***Please understand all information is confidential and will be used to help usminister to
and care for your child. ***
CAMPER’S COVENANT
SECONDBAPTISTCHURCH SUMMER CAMP 2010
A covenant is an agreement between two people or two groups. By signing this form, you are promising to follow these guidelines while you are at camp. Each person must sign a Camper's Covenant to be able to go to camp.
CAMPER'S COVENANT
As a participant at Second Baptist Church Summer Camp 2010, I agree to obey the following rules of cooperation in order to guarantee a Christian atmosphere and a good experience for all campers:
1. I will obey all requests and instructions of the CampDirector, Staff, and
Leaders.
2. I will not bring into the camp or use any cell phones, video games, radios, CD or
Mp3 players, IPODS, shaving cream, or other disruptive materials.
3. I will not bring any snacks, food, or candy to camp.
4. I will follow the camp schedule faithfully, being on time, in the right place, and
ready to participate as the schedule indicates. This includes wake-up and
lights-out times. (No one is permitted outside the cabins between lights out and
wake-up times.)
5. I will not use profane or dirty language while at camp.
6. I will participate fully in all activities of camp.
7. I will respect the property of the camp, Church, and other campers.
- I will not participate in any activity that would hurt another camper or leader such as fighting, practical jokes, hurtful words, or gossip.
- I will come to camp with an attitude of having fun and expecting to learn how God can use this experience in my life.
- I understand that if at any time I repeatedly break a clearly defined camp rule or am defiant of camp leadership, I will be sent home.
Camper’s Name (please print)
______
Camper’s Signature______
I have read and discussed the above covenant with my child & understand
that it is my responsibility to pick up my child from camp should the
camp leadership feel it necessary to send them home.
Parent's Signature______
Date ______
Registration and Medical Information
Parental Permission and Release
SECOND BAPTIST CHURCH CHILDREN’SCAMP – JUNE 14-18, 2010
**PLEASE NOTE – Form MUST be signed for form to be complete.
PLEASE PRINT
Student’s Name______Grade entering (Fall 2010) ______
Boy ____ Girl ____ Date of Birth______School______
Primary Address ______
City/St/Zip ______
Father’s Name______Mother’s Name______
Home Telephone ______Home Telephone ______
Business Telephone ______Business Telephone ______
Cellular Telephone ______Cellular Telephone ______
Emergency Contacts (Other than Parents)
Contact # 1Contact # 2
Name ______Name ______
Relationship to Child ______Relationship to Child ______
Home Telephone ______Home Telephone ______
Business Telephone ______Business Telephone ______
Cellular Telephone ______Cellular Telephone ______
Medical History and Current Information
Current Medical Problems ______Drug Allergies______
______Food Allergies ______
______Insect Allergies ______
Current Medications DosageSchedule
______
______
______
______
Parent/Legal Guardian’s Signature(s)______
Date:______
A copy of the front and the back of your Health Insurance Card must accompany this form for your registration to be complete.
Page 2
Please indicate if your child has ever had any of the following. If you mark yes to any condition, please explain
in detail below including date of diagnosis and current treatment.
YesNoYesNo
Diabetes/Hypoglycemia______Asthma______
Migraines ______Use Inhalers/Nebulizer______
Seasonal Allergies______GI Disturbances______
Skin Conditions/Disorders______ADD/ADHD______
Dental Appliances______Hospitalizations______
Glasses/Contact Lens______Seizures/Convulsions______
Explain:______
______
______
Any Special Conditions not listed above: ______
______
______
Medical Release
I/We, ______, the parent(s) of ______do hereby give
over and release unto the staff and chaperons of Second Baptist Church of Houston all authority and responsibility to authorize any and all medical treatment necessary for the protection of the health and well-being of my aforementioned child. This authorization shall authorize any and all medical treatment by licensed medical personnel, pursuant to the express authorization, whether written or oral of the above mentioned representatives. This authorization shall be effective June 14-18, 2010 inclusive or until it is expressly revoked.
I/We hereby grant permission for the Second Baptist Nurse or trained designate to administer over–the–counter medications, including but not limited to: Tylenol, Ibuprofen, Pseudophed, Claritin, Tums. Benadryl, Anti-Itch Cream, Delsym for cough, and Visine eye drops.
I/We do hereby release Carolina Creek Christian Camp, SecondBaptistChurch, their agents, employees, chaperons, and volunteers from any and all claims and liabilities of whatsoever nature, both individually and collectively, that may arise from my child’s participation in this event.
I/We understand that I/we will be financially responsible for any medical costs incurred in the emergency treatment and/or transportation of my child.
Transportation & Property
I/We further understand that my child will be transported in equipment owned, leased, or rented by SecondBaptistChurch. I/We understand that I/we are financially responsible for any damage caused by or in part by my child. This includes all private and public property.
Promotional Release
SBC has permission to use any photographs/video of the above named child for brochures, videos, advertising, web page, or other promotional items. I/we further understand that these photos/videos will only be used for SBC promotional purposes.
A copy of the front and the back of your Health Insurance Card must accompany this form for your registration to be complete.
I/We acknowledge that I/we have read and understand all aspects of both pages of this Registration and Medical Information/Parental Permission and Release.
I/We agree that copied representations of our signatures should be accepted as binding.
Parent/Legal Guardian’s Signature(s)______
Date:______
Carolina Creek Christian Camp
Participation Agreement & Waiver
Name of CampParticipant
I am above the age of 18 and am signing this agreement as the camp participant.
I, , am the parent/legal guardian of the came participant, a minor. I hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child my permission to attend Carolina Creek Christian Camp.
Furthermore, I consent to give my child permission to participate in all activities including, but not limited to, climbing, repelling, low rope elements, high rope elements, swimming, other water activities, and all indoor and outdoor events and activities. I understand all activities are optional and that my child or I have voluntarily applied to participate in the events and activities of the Camp. I understand the foregoing activities and all other events, hazards or exposures connected with the Camp and the indoor and/or outdoor activities, involve risk of harmand that accidents or illness can occur in places without medical facilities, physicians, or surgeons. I am aware of the risks and damages inherent with those activities and I knowingly and willingly assume the risk of injury.
Medical Information
Participant Name:
Mailing Address:
City: State: Zip:
Date of Birth: Phone:
Person to notify in case of an emergency:
Phone number(s) of emergency contact person:
Name of doctor and phone number:
General Health Information: Do you currently have any of the following?
1. Recent serious injury: Y N
2. Recent surgery: Y N
3. Allergies to medications: Y N
4. Food Allergies: Y N
5. Asthma: Y N
If yes to any of the above, please describe:
7. Do you take any medications regularly? Y N
8. If yes, will you have these with you? Y N
9. Has your camper received all vaccinations required to enter school in the state of Texas? Y N
10. Date of last Tetanus Shot
11. Add any other necessary medical information:
(Attach separate sheet if needed)
Insurance Information:
- Medical Insurance Company:
- Plan or Group Number:
- Insured Name:
- Insured I.D. # or Member #:
- Insurance Company Phone Number:
- Insurance Company Address:
Parent Signature ______
Date ______
Page 2
Authorization for Emergency Medical Treatment
I have listed above my or my child’s physical conditions or medical problems that may need attention and all medications regularly used by myself or said minor. I understand failure to disclose medical information/condition may result in dismissal from Carolina Creek Christian Camp. In case of the illness of myself or my child, Carolina Creek Christian Camp will try to notify whoever is listed as the emergency contact person. In the event there arises a medical emergency concerning myself or my child, at a time where the emergency contact cannot be notified, I authorize Carolina Creek Christian Camp to consent to any necessary X-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care. I hereby consent and give my permission to the Carolina Creek Christian Camp staff or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon myself or my child that may, in their sole discretion, be necessary and proper under the circumstances.
General Release and Waiver of Liability
I DO RELEASE, ACQUIT, DISCHARGE, AND COVENANT TO HOLD HARMLESS CAROLINA CREEK CHRISTIAN CAMP STAFF, PERSONNEL, OR ANY OF ITS REPRESENTATIVES FROM ANY ACTIONS, DAMAGES, OR LIABILITIES ARISING OUT OF ANY INJURIES OR PROPERTY DAMAGE SUSTAINED DURING THE PARTICIPATION IN THE CAMP AND/OR RESULTING FROM THE TREATMENT OF ANY ILLNESS, SICKNESS, OR ACCIDENT, INCURRED BY MYSELF OR MY CHILD DURING HIS/HER STAY AT CAROLINA CREEK CHRISTIAN CAMP.
In consideration for being permitted to attend Carolina Creek Christian Camp and participate in the activities conducted by the Camp, I, on behalf of myself, my child, my legal representatives, heirs and assigns, do hereby release, waive, and forever discharge Carolina Creek Christian Camp and its officers, employees, volunteers, and agents, of and from any and all loss, damage, claim, demand, action or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident that may occur as a result of my or my child’s participation in the camp activities or any activities in connection with the Carolina Creek Christian Camp, whether by negligence or not.
I, personally, and on behalf of my child (if child is the camp participant), hereby give Carolina Creek Christian Camp permission to use my and/or my child’s name, photograph, quotations and likeness in any advertisements or promotions performed in connection with the camp and agree that neither I nor my child shall be entitled to any compensation for such use.
I agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that if any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
X
Adult Participant or Parent/Guardian Signature
Printed Name and Address of Signatory:
Date: X
KID’S CAMP 2010
REGISTRATION/PAYMENT INFORMATION
Student Information:
Grade entering (Fall of ’10) ______Boy ____ Girl ____
Name:______
First Name Middle NameLast Name
Address:______
City:______State: ______Zip: ______
Home Phone: (______)______Name of School (’10 -‘11)______
Parent’s E-Mail (Give full address)______
Are you a member of Second Baptist? Yes _____No _____
If not, where? ______
Shirt Size (check one) ___ Youth Medium (10-12) ___Youth Large (14-16)
___ Youth X-Large (18-20) ___Adult Small
___Adult Medium ___Adult Large ___Adult X-Large
Please circle the campus your child will be riding the bus to and from camp:
Woodway West North
Type of Payment: Cash Check # ______Credit Card (fill out below)
Please make checks payable to Second Baptist Church
CREDIT CARD PAYMENT INFORMATION
Check ONE:____ Visa (Billing Zip Code ______)____ Master Card(Billing Zip Code ______)
____ Discover(Billing Zip Code ______)____ American Express(Billing Zip Code ______)
Name on Card ______Signature ______
Card Number:______Exp. Date: ______
I give my permission to charge my card with the following schedule (Check One)
Early Bird Registration:Regular Registration:Late Registration:
_____ Pay $350 balance in full_____Pay $375 balance in full_____Pay $450 balance in full
_____Pay $75 deposit only_____Pay $75 deposit only
_____ Pay $75 deposit with_____Pay $75 deposit with
balance of $275 charged balance of $300 charged
to the same card on 5/1/10.to the same card on 6/1/10.
Office Use Only Initial Payment: Date Charged ______Approval Code ______
2nd Payment: Date Charged ______Approval Code ______