2019 pineywoods camp retreats consent & release form


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Jan 18-21, 2019 / Parkway Fellowship

Pineywoods Baptist Encampment

2019 PINEYWOODS CAMP RETREATS CONSENT & RELEASE FORM Age 17 & Under --> Parent or legal guardian must complete form. 18 Year Olds & Other Adults --> Complete your own form. Camper Information Preferred Name (the first & last name he/she goes by): ________________________________________________ Legal Name (first middle last): __________________________________________________________________ Address:

Gender:

Male

Female

Birthdate ____________________ Age _________________ Emergency Contact (required) In an emergency, notify: Name (first & last): _______________________________________ Relationship to Camper: ______________ Primary Phone Number: (________) ____________________ Alternate Emergency Contact (optional) Name (first & last): _______________________________________ Relationship to Camper: ______________ Primary Phone Number: (________) ____________________ Pertinent Medical History/Condition(s) & Special Instructions: ______________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Known Allergies: __________________________________________________________________________ _________________________________________________________________________________________ Current Medications & Instructions: ___________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Immunizations Current:

Yes

No

Is Camper Currently Under Doctor’s Care:

Do not immunize (for personal, medical, or religious reasons) Yes

No

(if yes, provide Doctor information below)

Doctor Name __________________________________________

Phone Number ____________________

Doctor Address ___________________________________________________________________________ ___________________________________________________________________________ Continue to Next Page

2019 Pineywoods Camp Retreats Consent & Release Form (page 2)

I have read and understand the camp rules. I give my permission for the named camper to take part in any and all activities occurring within the camp program. I agree that my child (or I) will abide by the camp rules while at Pineywoods Baptist Encampment. If my child (or I) does (do) not abide by these rules, I understand that he/she (or I) could be sent home at my expense at the discretion of the camp director and camp administration. I also give permission for the use of photographs of my child (or myself) taken while at camp to be used in the promotion of Pineywoods Baptist Encampment on the Pineywoods Camp web page or printed materials. I hereby give my permission for medical treatment, including administration of first aid and/or OTC medication(s), if deemed necessary by camp medical personnel. In the event of an emergency I hereby give my consent for Pineywoods camp administration or church leadership to sign for and obtain emergency medical care should it be necessary. I acknowledge and understand there are inherent risks associated with many camp activities. I understand that every effort will be made to provide the safest camp environment possible, but that accidents can and do occur. I assume the risks and agree not to hold liable the sponsoring church, the camp staff, or Pineywoods in the case of an unforeseen event at camp or within the camp program. I acknowledge the information I am providing is accurate and true.

Signer Relationship to Camper: Signature ______________________________________________________ Parent

Guardian

Self

PINEYWOODS CAMP RULES - RETREATS (revised 2/7/14) Pineywoods is a Christian camp and all rules are to help us to reflect Christ in our conduct. Please respect all camp properties just as you would at the church you attend. We ask you to assist in keeping the grounds clean of trash. Cans are provided camp wide to contain debris. Illegal drugs, alcohol, knives, ANY form of tobacco, guns, skateboards, and fireworks are not permitted. Such items will be confiscated. If property or equipment is damaged by any member of your group, your group will be held responsible for any cost incurred for repair or replacement. If dorm room is excessively filthy during your stay or upon departure, your church will be assessed a fine of at least $50. The lake is for canoeing, kayaking, or fishing. The lake is not approved by the Health Department for swimming. A lifeguard must be present, and lifejackets worn while a camper is in any boat. Pineywoods requires two adult sponsors in each dorm room. Sponsors must be at least 18 years old and be approved by their church pastor. Shoes must be worn at all times (unless a camper is in the pool or on sand volleyball courts). No clothing which is revealing, suggestive, or advertises alcohol or tobacco products will be allowed. Swimsuits must be modest – no bikini- or monokini-style or a colored t-shirt must be worn while at the pool. Lifeguards have discretion and can eject anyone not properly clothed from pool area. Shaving cream fights, water fights, etc. will not be tolerated. A group doing such in or near enough a building to cause damage, will face a charge of at least $100. No use of the adventure park, tower, swing, low ropes course, or pool is allowed unless Pineywoods authorized, trained personnel are present. Campers are not allowed to enter dorms of campers of the opposite sex. Campers are not allowed to leave the campgrounds while at camp. Campers must attend all scheduled sessions and activities. Campers are not allowed to ride in or on any vehicle at camp. Campers are not allowed to share ANY medication belonging to them with any other camper. No golf carts, four-wheelers, or ATVs of any kind are allowed on camp except those used by the camp staff or unless pre-approved by camp management.

All of the above rules are designed to provide a Christian atmosphere, a safe and healthy environment, and provide for the respect of the camp and facilities. Please see to it that all campers are aware of these rules before your retreat begins.

Pineywoods carries an accident policy on registered guests. This policy is intended to supplement your own insurance, and will pay only to its limits. There is no deductible. Sickness and pre-existing conditions are not covered. This policy will pay only for accidents immediately reported to Pineywoods. This insurance does not cover members who leave the grounds during your stay. Unauthorized activities may not be covered. Claims must be reported on forms provided by Pineywoods.