Registration Form for Camp Grace Junior Camp June 12 – 15, 2012 Please print neatly on both pages! Camper Last name: ___________________________ First: _____________________ Age: _____ Male/ Female Address____________________________City______________________State_____ Zip Code_________ Date of birth ___/____/___ Grade this coming year___ Parents’ names: ____________________________ Home phone (____) _____________________ Work phone (____) _________________ Camper Health Form In case of Emergency: Other persons to notify if parents cannot be reached: Name______________________________________ Relation________________ Phone: _____________ Name______________________________________Relation_________________Phone: _____________ Past Illnesses: (please circle any that the child has had) Diphtheria Whooping Cough Scarlet Fever Chicken Pox Mumps Polio Rheumatic Fever Tuberculosis Other: _______________ Existing Diseases or Conditions: (please circle and explain current condition) Sinus Asthma Heart Kidney Epilepsy Diabetes Current Condition/Treatment: ________________________________________________ Does the child have any significant history of the following: (please circle) Nose bleeds Headaches Sleep walking Fainting Sore Throat Diarrhea/ Constipation Frequent colds Other: _________________________________ Allergies: (please circle and specify) Penicillin Bee/wasp stings (specify treatment) _________________________________ Foods____________________________________________________________________ Other: __________________________________________________________________ Immunization Record: (Record last date of injection.) Tetanus_________________ Polio_______________ Diphtheria___________ Whooping cough_______________ Smallpox___________________ Insurance Information: (please complete fully) Company____________________________ Name of holder___________________ Policy #_____________________________ Group #_________________________ ALL MEDICINE MUST BE IN ITS ORIGINAL CONTAINER-CLEARLY MARKED WITH THE CHILD’S NAME AND DOSAGE. In case of emergency: I give permission for my child to be given over-the-counter medicine(s) for minor ailments. I also give permission for my child to be transported to, and treated at a medical facility in the event of an emergency. ________________________________ __________________ Signature of parent or guardian) (date)
(OVER PLEASE)
Consent and Release Form I, the undersigned parent or guardian, hereby consent to my child’s participation in the “Camp Grace Junior Camp.” This includes the transportation of my child to and from certain excursions that the camp will participate in. I certify that my child is able to participate in all activities (except______________________________________). I will assume full responsibility, including all costs, if my child should need to be transported home, including for disciplinary reasons. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them on the health form. In the event an emergency occurs, I may be reached at the telephone number provided above. If I cannot be reached, I herby authorize the adult sponsor in charge to make emergency medical decisions for my child. I understand and hereby agree to assume all of the risks which may be encountered on said activity, including activities preliminary and subsequent thereto. I do hereby agree to hold Freddie Coile, Focus Evangelistic Ministries, Grace Farm, and their agents harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which participant now has or which may arise in the future in connection with the activity or participation in any other associated activities. Permission is granted for the use of images or recordings that may include my child for promotional purposes. I expressly agree that this release waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Georgia and that if any portion thereof is held invalid, it is agreed that the balance shall notwithstanding continue in full force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understand. ____________________________________________________________ _____________________ Parent or guardian’s signature ____________________________________________________________ _____________________ Witness signature * Electronic Devices Policy: Electronic devices are not allowed at camp. Camp is a life-changing experience that is better without distractions. Do not bring electronic devices to camp. If a parent desires cell phone contact with a child this is allowed if the phone is turned in to the Happy Shack and calls may be made daily during a time when the Happy Shack is open. Mail registration with payment ($95) to: Focus Evangelistic Ministries 2694 Hwy 174 Danielsville GA 30633
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