Rescue Youth Latham Springs Registration & Liability Release | FBC Cuero
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Email *
Name of Church: *
Camper's Last Name: *
Camper's First Name: *
What is your campers T-Shirt size? *
Are you filling out this form for a Camper (under21) or an Adult Sponsor (over 21) *
I understand that if I am an Adult Sponsor (over 21), I must also provide a paper copy of the appropriate Child Protection Training completion certificate (required by the Texas Department of State Health Services) at camp registration or to Camp Leadership for EACH camp I attend. *
Required
What is the participant's full address? (Including Street, City, State, zip) *
Participant's Date of Birth: *
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Age of Participant/Camper at time attending camp: *
Participant's Gender: *
Is the Participant a Christian? *
Parent's/Legal Guardian's Name (First & Last): *
Parent's/Legal Guardian's Relation: *
Parent's/Legal Guardian's Cell Phone: *
Parent's/Legal Guardian's Home Phone: *
Parent's/Legal Guardian's Work Phone: *
Parent's/Legal Guardian's Email: *
Doctor's Name: (Type N/A if there is none) *
Doctor's Phone number: (Type N/A if there is none) *
Date of last Tetanus shot/booster (if known; type unknown if you're not sure.) *
Is the camper/participant allergic to a Tetanus booster? *
Is the camper/participant up to date on immunizations? *
Health History: list ANY recent illnesses, injuries. procedures, conditions and/or hospitalizations relevant to a physician in case of an emergency: *
Allergies to medications or other (and describe response to allergen): *
List any food allergies the camper/participant has (and describe response to ingestion or proximity): *
I understand that if the camper/participant requires any dining hall accommodations related to these food allergies, I must complete the Food Allergy & Special Dietary Need form and fax to Latham Springs no later than two (2) weeks prior to the camp start date. *
Required
Medication Acknowledgement: *ALL MEDICATIONS, whether prescription or over-the-counter, MUST be in the ORIGINAL container with the camper’s name and the current dosage (required by the Texas Department of State Health Services). All medications must be placed in a Ziploc bag with your child’s name and church name, and MUST be given to the Camp Nurse during registration. If your child/youth requires an asthma inhaler or antidote for insect bite or allergies (prescribed by doctor), have them bring at least two (2) to camp. The medication must be registered with Camp Nurse. One (1) will be kept and closely guarded by camper and one (1) given to the Camp Nurse. Similar special cases must be discussed with Camp Nurse. If the need arises, I give my permission for my child/youth to be inspected for head lice/eggs. I understand any such check would be conducted sensitively. I understand Latham Springs’ Notice of Privacy Practices uses and disclosure of health information about my child/youth to the group leader, director, his designee, the child’s sponsor and medical staff, when in its sole discretion, believes such communication to be in the best interest of my child for treatment, to obtain payment for treatment, administrative purposes and to evaluate the quality of care that he/she receives. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. *
Required
Camper/Participant's approximate WEIGHT during camp visit (for medical/emergency purposes): *
Camper/Participant's approximate HEIGHT during camp visit (for medical/emergency purposes: *
I hereby authorize the Latham Springs Camp & Retreat Center staff, Camp Nurse or Group Leadership to make Emergency medical decisions for my Child/Youth and I understand that my insurance will be primary coverage. *
Required
Who is your insurance provider? (Type N/A if there is none.) *
What is your insurance policy number? (Type N/A if there is none) *
What is your insurance I.D number? (Type N/A if there is none) *
Please Provide an Emergency Contact With their NAME, PHONE NUMBER, and RELATIONSHIP to the Camper. *
Please Provide a second Emergency Contact With their NAME, PHONE NUMBER, and RELATIONSHIP to the Camper. *
Name of Medications (in original containers) that will be brought to camp along with DOSAGE, FREQUENCY it is taken, TIMES to be administered, and any other COMMENTS or instructions for the Camp Nurse (including inhalers or rescue medications): *
I give permission to the Camp Health Officer (Camp Nurse) to administer over-the-counter medications as needed and as directed on the label, EXCEPT FOR: (Type N/A if there are no exceptions) *
Camper Pick up Policy: Remember that the continuity of the camp experience is used by the Holy Spirit to touch campers’ hearts. Taking a camper out for even a brief period can reduce the spiritual effectiveness of camp. Please minimize absences. Written permission must be provided to the camp before a child will be allowed to leave with any person other than listed below. *
Required
Please Provide an Authorized person to pick up your camper With their NAME, PHONE NUMBER, and RELATIONSHIP to the Camper: *
Please Provide a second Authorized person to pick up your camper With their NAME, PHONE NUMBER, and RELATIONSHIP to the Camper: *
List any activities you or your camper does not want to participate in. Please, be sure to notify sponsors of this request: *
“CAMP” means LATHAM SPRINGS BAPTIST CAMP, INC. or LATHAM SPRINGS CAMP & RETREAT CENTER, INC., a Texas nonprofit corporation, its Member Churches, Directors, Officers, Employees, Agents, Volunteers, or Associates. “Applicant” means campers and all participants in CAMP activities, and the parent, legal guardian or conservator of any campers and all participants in CAMP activities, who verifies by this signature that he or she has the legal right to sign on behalf of camper or participant less than 18 years of age (Minor), and Applicant’s heirs, executors and administrators, successors and assigns, and members of Applicant’s family, including any minors accompanying Applicant. “Risks and Dangers” include, but are not limited to, the negligence or intentional acts of other people, including other campers, drowning or other water injury, falls or injury from heights (ground to 50 feet), accident or illness in remote places without medical facilities, the forces of nature, and travel by air, boat, automobile, or other conveyance, elements of nature, including temperature extremes, inclement weather, poisonous plants, biting or stinging insects, animals, rough outdoor terrain, and possibly high altitude, including the possibility of asthmatic or allergic attack. *
Required
Consideration Acknowledgement: Applicant is a camper at CAMP, or potential participant in CAMP Activities. This agreement is made in consideration of CAMP leaders allowing Applicant to participate in such activities: All Applicants must sign this agreement before being allowed to participate in CAMP activities. *
Required
Risk Notice Acknowledgement: Applicant acknowledges that these Activities involve inherent Risks and Dangers and that Applicant will be exposed to these Risks and Dangers. Applicant recognizes that these Risks and Dangers may cause personal injury or death, loss or damage to personal property, emotional distress, and psychological damage due to accidents or intentional acts which may occur during these activities. Applicant understands that transportation for medical treatment may take an hour. *
Required
Applicant's Health Acknowledgement: Applicant certifies Applicant is completely physically, mentally, psychologically, and emotionally healthy, and capable of participating in all Activities, except for those listed below. Applicant has specified in detail any reasonable accommodation necessary for any disability that Applicant may have and has supplied equipment, medicine, or medical supplies that Applicant may need. Applicant understands that participation in this CAMP program is entirely VOLUNTARY. Applicant is solely responsible for determining whether there is any reason that Applicant should not participate in any Activities, including possible contact with any substances that may cause asthma or allergic reactions. *
Required
Release Acknowledgement: In consideration of, and as part payment for the right to participate in Activities and the services and food arranged by CAMP, Applicant: (1) fully releases CAMP from current or future liability from negligence, gross negligence, or intentional tort by any person, (2) assumes all Risks and Dangers, whether or not that risk is foreseeable, and (3) will indemnify and hold CAMP harmless from any and all claims, liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, for personal injury, property damage or loss, psychological injury or emotional distress, or medical expenses of any kind and attorney’s fees and costs of court filed by Applicant, or by other parties against CAMP, connected with Applicant’s program or participation in any activities at CAMP or arranged by the CAMP. *
Required
Second Release Acknowledgement: Applicant hereby agrees that Applicant will not sue CAMP for personal or property injury, and, if Applicant attempts to sue, Applicant will not collect any money. In addition, Applicant will indemnify CAMP for attorney’s fees and costs of court fees associated with any litigation against CAMP connected with Applicant’s program or participation in any activities at CAMP or arranged by the CAMP. *
Required
Safety Acknowledgement: Applicant will wear shoes and socks and bring and apply sunscreen as necessary. Applicants who are minors or with youth groups will not leave the CAMP grounds, authorized areas, or vehicles transporting Applicant at any time without permission, and Applicant agrees that CAMP is not responsible if Applicant violates this rule. Applicant agrees to follow all safety instructions and to use caution to protect Applicant, other camper, CAMP personnel, and others. Applicant understands that failure to obey safety rules will cause expulsion from CAMP. *
Required
Camper Statement Acknowledgement: I agree to obey all rules (rules having to do with safety and Christian behavior) and regulations of Latham Springs Camp &Retreat Center, and will cooperate with leaders and fellow campers and with the camp staff at Latham Springs. *
Required
Family Authorization Acknowledgement: In consideration for your agreeing to accept the above-named individual as a camper, I/we hereby assume all risk in connection with participation in the above-named Christian camp. I/We authorize medical and surgical treatment for my child as may be needed in the judgment of the treating physician (physician chosen by Latham Springs management). I/We understand twenty-four-hour first aid care is available on the campgrounds, and I authorize transportation of my child at their discretion in case of emergency. I/We further understand that only limited secondary accident coverage ($2,500 maximum) is provided. I further give permission and consent to Latham Springs Camp & Retreat Center for any photographs, videotapes and interviews to be taken during the camping session to be published and used to illustrate, report, promote and advertise the camp including on Internet Web Sites promoting or reporting on the camp. I hereby assign full copyright of these photographs to Latham Springs Camp & Retreat Center with the reproduction either wholly or in part. *
Required
SIGNATURE OF CAMPER/PARTICIPANT: by typing my first and last name below, I verify that I have read and understand every provision of this agreement. *
SIGNATURE OF PARENT/GUARDIAN/CONSERVATOR: by typing my first and last name below, I verify that I have read and understand every provision of this agreement. *
Provide the Date this form was filled and signed:
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A copy of your responses will be emailed to the address you provided.
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