July REGISTRATION FORMS. Chesapeake Summer Camp Enclosed Forms Parent Should Complete and Return: Enclosed Information Parent Can Keep:

Transcription

1 REGISTRATION FORMS Chesapeake Summer Camp 2010 July Enclosed Forms Parent Should Complete and Return: Page 2 Registration Form Page 3 Health Form Page 4 Release Form Page 5 Paintball Release Form (if teen might participate in paintball) Enclosed Information Parent Can Keep: Camp Dates This page Camp Information Page 1 Camp Rules Page 6 For Additional Information Back Cover

2 Register Now. Space Limited. Arrival: Monday at 1 pm Departure: Saturday at 11 am Be Ready For: Rallies Paintball Frisbee Golf Dynamic Speaking Team Competitions Intense Worship Swimming + More Bring: Bedding (Sheets or Sleeping bag, Pillow) Toiletries and Towels Casual/Play Clothing (Modest Please) Bible/Note Pad/Pen Bathing Suit (One Piece, No Speedos) Paintball Gear (MUST Check it in at Registration) Money for Paint Balls Don t Bring: Personal Electronics (Ipod, Cell Phone, PSP...) Any Tobacco, Alcohol, or Non-Prescription Drugs Any Weapons (Including Knives of ANY Kind) Any Clothing With Obscene Language or Pictures 1

3 Chesapeake Summer Camp 2010 Registration Before June 1st: $195 Early Bird Special! ($100 of this cost is non-refundable) After June 1st: $245 ($100 non-refundable deposit due by July 1st ) Walk-ins: Placement Not Guaranteed Payment must be submitted with this form to register (or full payment of $195 if registering before June 1st). Camp t-shirts are an additional $10. Please make checks payable to Chesapeake Wesleyan Youth. Please Complete this form and return to: Attention: Pastor David Zimmerman First Wesleyan Church 620 Goldsborough St. Easton, MD Teen s Information Home Church: Youth Pastor: Teen s Name: Teen s Address: City: State Zip Phone:( ) Teen s Address: Gender (check one): Male Female Grade Entering Fall of 2010: (circle one) n/a Roommate Preference #1 Roommate Preference #2 Emergency Contact Information Name: Relation: Home Phone: ( ) Alt. Phone: ( ) Address: Pre-order tshirt Please add $10 to total check amount S M L XL front back shirt color is yellow 2

4 Health and Insurance Information Allergies (check all that apply): Hay Fever Poison Ivy Insect Stings Penicillin Asthma Other Drugs Immunization History (check one for each): DPT Series Polio OPV (sabin) German Measles Measles Vaccine (live) Mumps Tetanus (Give Date) Other (explain) Health History (check or give approximate dates): Diabetes Rheumatic Fever Bed Wetting Ear Infection Convulsions Sleepwalking Communicable Diseases (please explain): Special Needs Dietary Restrictions: Food Allergies: Special Diet: Notes to Nurse: Health Insurance Health Insurance Co. Policy Number: Insurance Co. Phone:( ) Family Physician: Family Physician Phone:( ) 3

5 Release In the event of an emergency/medical or hospital care: 1. We will call the home. If there is no answer We will call the father s, mother s, or guardian s place(s) of employment. If there is no answer We will call the other telephone number(s) listed and the family physician. 4. If none of the above answer, we will call an ambulance, if necessary, to transport the teen to a local medical facility. 5. Based upon the medical judgment of the attending physician, the teen may be admitted to a local medical facility. 6. We will continue to call the parent(s), guardian(s), or physician until one is reached. I, parent/guardian of,, have familiarized myself with the information concerning the Chesapeake District IGNITE Youth Camp and its activities. I hereby certify that all of the information contained in this registration form is correct. I expressly waive any and all claims against the Chesapeake District of the Wesleyan Church, or any of its District Boards, or its representatives due to any injury or other damage that may be incurred by my minor child/ward or said registrant s property in connection with, or incident to, the Chesapeake District of the Wesleyan Church IGNITE Youth Camp program. If I cannot be reached and the District authorities have followed the procedures described, I agree to assume all expenses for moving and medically treating this participant. I also hereby consent to any treatment, surgery, diagnostic procedures or the administration of anesthesia which may be carried out based on the medical judgment of the attending physician. By signing below I give my permission for my child/ward to participate in all camp activities and understand that he/she may be sent home if found in violation of any camp rules, and I further agree to have them picked up immediately. Parent/Guardian Signature (in ink): Date: Permission for Medications Please check all that your child may receive from nurse. (as needed) Tylenol (acetaminophen) Tums or similar antacid (calcium carbonate) Advil (ibuprofen) Benadryl (diphenhydramine) 4

6 American Paintball League THIS IS A RELEASE OF LIABILITY -- READ BEFORE SIGNING NOTE: THIS FORM MUST BE READ AND SIGNED BEFORE THE PARTICIPANT IS ALLOWED TO TAKE PART IN ANY PAINTBALL EVENT. Participant Information (please print) Participants Name: Date of Birth: / / IN CONSIDERATION of being permitted to participate in any way in the sport and activities of paintball under the auspices of the AMERICAN PAINTBALL LEAGUE, I acknowledge, appreciate, and agree that: 1. The risk of injury from the activity and weaponry involved in paintball is significant, including the potential for permanent disability and death, and while particular protective equipment and personal discipline will minimize this risk, and the risk of serious injury does exist; 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLEGENCE of those persons released from liability below, and assume full responsibility for my participation; and, 3. I understand that the activities of paintball are physically and mentally intense. I understand the rules of play and will comply with all rules and regulations. If I observe and unusual or unnecessary hazard during my participation, I will bring such to the attention of the nearest official as soon as practical; and, 4. I, for myself and on the behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS FROM LIABILITY THE AMERICAN PAINTBALL LEAGUE (APL), the owners and lessors of premises used to conduct the paintball activities, their officers, officials, agents and/or employees ( Releasees ), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLEGENCE OF THE RELEASEES OR OTHERWISE, except that which is the result of gross negligence and/or wanton misconduct. 5. I understand and agree that this Release of Liability Agreement covers each and every paintball activity and event in which I participate hereafter. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Participant s Signature : Date Signed: / / Phone: ( ) Address: City: State Zip Address: FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree not only to his/ her release of the American Paintball League (APL) and all other Releasees from any liabilities incident to his/her involvement in these programs for myself, my heirs, assigns, and next of kin. 5 Parent/Guardian Signature: Date Signed: / / EMERGENCY PHONE NUMBERS ( ) ( ) ( )

7 Camp Rules Boy s areas are off limits to girls Girl s areas are off limits to boys No leaving camp without permission Kitchen is off limits Waterfront is off limits when not staffed NO ONE leaves dorm after lights-out No disrespect of people or property No bad language Clothing must be modest Girls must wear t-shirts over swimsuits Boys must wear t-shirts on playing fields No electronic devices (phones, ipods, games, etc.) No outsiders permitted Camp director s decisions are final Any campers who arrive at camp sick, feverish, or with any type of contagious sickness / illness will be sent home immediately! Registration Information Space is limited, register now Completed registration form must be accompanied by the Health and Release forms Medicines must be logged with the Staff Nurse upon arrival at camp Paint ball gear must be checked in upon arrival at camp Emergency Phone Calls During Camp Parents should call only for emergencies (410) or (703) Camper s Mailing Address During Camp (Your Camper s Name Here) Wesleyan Camp and Conference Center 424 E Wesley Circle Denton, Maryland

8 For More Information: Pastor Allen Perdue Fireside Wesleyan Church 4295 Aiken Drive Warrenton, VA (540) ext 111