TODAY I MADE A DIFFERENCE
Mission Camp 2014
March 18 (check in no later than 10 a.m.) through
Thursday, March 20 (check out by 9 p.m.)
Mission Camp is open for 6th – 12th graders
$50 Cost
WE HAVE LIMITED SPACE SO IT IS ON A FIRST COME, FIRST REGISTERED BASIS.
This year, we will be working with the Volunteer Logistics Coordinator of the OKUMC Disaster Response handling the rehab work from the tornadoes for the Moore, Shawnee, and El Reno areas.We will be staying at Christ Memorial, El Reno. We will gather at the Episcopal Diocese, 924 N Robinson, OKC, OK, on the 18th. That afternoon, we will be going to The OKC Red Cross and stuffing Safety preparedness bags for them. We will go to Tulsa on Wednesday and work with New Hope at Trinity Episcopal Church. On Thursday, we will shop, prepare, cook, and serve a meal at Christ Memorial, El Reno, for those building, volunteers, and homeowners in the area. PARENTS WILL BE ABLE TO PICK YOU UP AFTER 8 P.M.
Community Covenant and Image Release - Mission Camp
Expectations
I AGREE to be present at all planned activities, abide by the established curfew, refrain from the use of CD players, radios, I-pods, and cell phones, and follow all rules and guidelines of Mission Camp as set forth by the Mission Camp Staff, and All Souls’ Episcopal Church Staff.
I UNDERSTAND that any violation of the above Expectations may result in my expulsion from Mission Camp.
Rules
I AGREE that I will not possess or use alcohol, illegal drugs, firearms, knives, weapons, or fireworks, or possess or use tobacco products if I am under the age of 18.
I AGREE that I will not engage in inappropriate sexual behavior or behavior which could endanger fellow Mission Campers, Staff or Christ Memorial Church, El Reno staff.
I UNDERSTAND that any violation of the above Rules will result in my expulsion from Mission Camp.
Image Release
In consideration of the below participant, a minor, being permitted to participate in Mission Camp, I parent listed below, give the Episcopal Diocese of Oklahoma the right to use photographic, digital, and electronic images of said participant for Diocesan purposes, including but not limited to Diocesan publications, advertising, and websites.
I waive any right to inspect or approve the finished produce in which the image is used.
I hereby release, discharge, and agree to hold harmless the Episcopal Diocese of Oklahoma, Inc., and its representatives for and against all claims by or through me arising from the use of the image.
I understand there will be no compensation for the use of the image.
Signature and Understanding
I have read and understand the Community Covenant and Image Release and agree to accept the consequences should I violate a Rule or Expectation.
Camper Signature:______Date:______
I have read and understand the Community Covenant, and agree that should my child or dependent require expulsion from Mission Camp for violation of a Rule or Expectation, it will be at my cost.
Parent or Guardian Signature:______Date:______
Health Information Form 2014
CHILD’S NAME ______DOB______Social Security #______
Permanent Address____ Gender M F Home Phone ______
City, State, Zip Cell Phone ______
Food/Drug/Insect Allergies
Date of Last Tetanus Shot Height Weight
Emergency Contact Information If different from registration form
Name Relationship Phone #
Name Relationship Phone #
Insurance Information
Policy Holder’s Name Relationship __ Phone Number
Policy Holder’s Employer
Insurance Provider Policy #Plan #
Primary Care Physician Physician Phone #
Medical Treatment Consent
This health history is correct and complete as far as I know. The person herein named has permission to engage in all Mission Camp activities except as noted. I hereby give permission to Mission Camp to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for Mission Camp to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that Mission Camp be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of Mission Camp be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510(b)) to the disclosure to Mission Camprepresentatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to Mission Camp representatives related to the person’s ability to participate in Mission Camp activities; and (ii) in the case of minors, to provide relevant information to Mission Camp representatives to keep me informed of my child’s health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Mission Camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of Mission Camp.
______
Signature of parent or guardian Parent SS#
Printed Name Date
Current Prescription and Over-the-Counter Medications - Please list ALL medications, even items like eye drops. Participants will be responsible for their own medications with the exception of any controlled substances, which will be held by Mission Camp Staff.
Name of MedicationDoseTime(s) to be Taken Reason for Medication
Specific concerns/physical restrictions/accommodations (e.g. recent changes)