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Summer Camp Registration Form |
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MEDICAL AND LIABILITY RELEASE (Please print with blue or black ink only)
NAME ___________________________________ AGE _____ DATE OF BIRTH______________ Male_____ Female_____ Last Name First Name DATE OF CAMP ___________________ CHURCH or SCHOOL (through whom registered)__________________________
ADDRESS ___________________________________________ CITY _______________________ STATE____ ZIP ______
HOME PHONE (_____) _________________ CELL PH. (____)______________ IN EMERGENCY NOTIFY ____________________________________________PHONE (____) _____________________ FAMILY DOCTOR __________________________________________________ PHONE (____) _____________________
Little River’s insurance is only secondary insurance. Your medical insurance carrier will be billed for medical charges in case of illness or injury while your child is in camp.
Name of Insurance Company ______________________________________________Policy Number __________________
Insurance Company Address _______________________________________________
WELLNESS POLICY: All campers should be free of the following symptoms for at least 24 hours prior to start of the Camp Session: fever of 100 degrees or more, vomiting, diarrhea, contagious skin infection, or lice. Campers with these symptoms will need to return home for treatment. In the event of injury or illness, parents will be notified and are expected to come and pick up their camper. HEALTH HISTORY: _____Drug Allergies _________________________ _____Heart Condition _____Behavior/Nervous Disorder _____Food Allergies _________________________ _____Asthma _____Physical Handicap _____Environmental Allergies__________________ _____Seizure Disorder _____Stomach Problems _____Insect Stings___________________________ _____Diabetes _____Other
If any of the above are checked, please give details (i.e. include normal treatment of allergic reactions) ____________________________________________________________________________________________________________________________________________________________________________________________________________
Date of last tetanus shot:___________________
Name, dosage, and frequency of any medications that must be taken regularly, or as needed: ____________________________________________________________________________________________________________________________________________________________________________________________________________
Any swimming restrictions: Yes____ No____ Any activity restrictions: Yes____ No____ What restrictions? ____________________________________________________
If your child should require medical attention at camp for injuries received or illnesses contracted prior to coming to camp, please send us the information necessary to give your child proper medical service during your child’s stay at camp. ___________________________________________________________________________ ___________________________________________________________________________
This form may be copied and given to the camp at registration if there is information pertinent to the care of your child. Please initial if you would like this medical information to remain completely confidential.________
MEDICAL RELEASE: In the event I cannot be reached in an emergency during the camp dates as shown on this form, I hereby give my permission to the representative selected by Little River to hospitalize, to secure proper treatment for my child as deemed necessary. I also authorize the nurse/EMT during the incident to administer medical aid as required for illness or injury under a physician’s orders. The signature of the parent or guardian below is intended to serve as a medical release.
Parent or guardian’s signature ______________________________________ Relationship to child ____________________
Print Name ______________________________________Spouse’s Name________________________ Date ___________
Participation, Release, Waiver & Indemnity Agreement
WHILE LITTLE RIVER CHRISTIAN CAMP MAKES EVERY EFFORT TO PROVIDE A SAFE AND PLEASANT ENVIRONMENT FOR YOUR CHILD, WE DO REQUIRE THAT THIS PARTICIPATION AGREEMENT BE READ, FILLED OUT, SIGNED AND DATED BY THE PARENT OR LEGAL GUARDIAN OF EACH CHILD UNDER 18 YEARS OF AGE WHO WISHES TO PARTICIPATE IN THE ACTIVITIES WHICH OCCUR AT LITTLE RIVER CHRISTIAN CAMP. I, the undersigned, give permission for my son or daughter to participate in the activities that occur at Little River Christian Camp including scheduled all camp activities that take us off camp property. These activities include, but are not limited to, swimming in Little River or at the YMCA in Roseburg, Low Ropes Course, trips to Diamond Lake for recreation purposes, Trips to Glide for recreational purposes and strenuous competition games. I grant this permission with full knowledge that I accept full responsibility for any injury or accident that may occur. Although Little river Christian Camp has taken reasonable steps to provide equipment and skilled employees so your child can participate in activities for which he/she may not be skilled in, we now remind you that these activities are not without risk. Certain risks cannot be eliminated due to the Camp’s rural setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury or illness or, in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about inherent risks. For promotional or marketing purposes, Little River Christian Camp reserves the right to use any audio, video, and/or photography of guests or campers participating in Little River events. I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Little River Christian Camp, its supporting churches, General and Executive Board, or employees, for any and all claims for injuries, causes of action, or liability related to my child’s participation in any activity occurring at Little River Christian Camp, or on or around the Umpqua National Forest. This release does not apply to intentional and/or willful acts of misconduct by Little River Christian Camp supporting churches, General and Executive Board, or employees. Should Little River Christian Camp, or anyone acting on their behalf, be required to incur attorneys’ fees and costs to enforce this agreement, I agree to Indemnify and hold Little River Christian Camp harmless for all such fees and costs. By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child’s participation in these activities, I and/or my child may be found by a court of law to have waived any right to maintain a lawsuit against Little River Christian Camp on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound by its terms.
Parent or guardian’s signature _____________________________________________________ Date ___________________
Print name __________________________________________________ Relationship to child _________________________
Camper’s Name________________________________________
LITTLE RIVER CHRISTIAN CAMP 351 CHRISTIAN CAMP LANE, GLIDE, OR 97443 Phone (541) 496-3239 Fax (541) 496-3239 Fill out and return to your church. If you have no church, please mail or fax to camp. |