JR High Camp

---

JR High Camp

Summit Camp 2016 (Junior High Camp/Students going into 7th and 8th Grade)

June 13th-17th Cost - $125 (Scholarships available w/ scholarship application)

Parent/Camper Meeting Sunday, June 5th @ 12 pm 3rd Floor All Scholarship applications are due by June 5th. No Scholarships will be given after that date.

GRAND LAKE BAPTIST ASSEMBLY

2016 Summit Camper Health Form – Youth Week @ GLBA Personal Information Church ______________________________________________________

Cabin Staying In ________________________________________

Pastor /Youth Pastor ____________________________________________

e-mail Address ____________________________________________

Camper Name _________________________________________________ Sex _____________ Age ___________

Grade ___________

Address ______________________________________________________ Phone (_____)___________________________ City __________________________________________

State _____________________________

Camper’s Date of Birth: _________________________________

Zip __________________

Social Security # and CDIB #: _____________________________________

Health Information Do you have allergies? (Please List) __________________________________________________ Date of last tetanus shot ____________________ Medicine(s) you are presently taking _________________________________________________

Blood Type (if known) _____________________

Special conditions/information we should be aware of ______________________________________________________________________________ Your physician’s name _____________________________________________

Office telephone number (_____)___________________________

Parent/Guardian __________________________________________________________________________________________________________ Home Phone (_____)____________________________________________ Work Phone (_____)______________________________________ Emergency contact person __________________________________________

Emergency telephone number (_____)__________________________

Health Insurance Information Primary Insurance (your private insurance)

Secondary Insurance (Excess Coverage)

Company Name _____________________________________

Guide One Insurance Company

Address ____________________________________________

Limits: $25,000.00 max per camper

City _______________________State______Zip___________

Accidental death & dismemberment: $10,000.00

Phone ______________________________________________

Dental: $1,000.00

$0 Deductible

Policy No. ___________________________________________

Everyone MUST make a copy of their Insurance Card and attach it to this form: Summit Code of Behavior 1.

All campers are expected to participate in classes and worship services.

2.

Campers are expected to respect the camp property as well as the personal property of others.

3.

Immodest clothing, distasteful monograms, or any other extreme style of attire is prohibited.

4.

Campers are to maintain the highest moral standards of the Christian faith.

5.

Tobacco, alcoholic beverages, illegal drugs, firearms, and fireworks are prohibited on the campgrounds.

6.

Vehicles are not to be driven on the campgrounds unless absolutely necessary.

7.

No tape players, CD players, or radios are permitted on the campgrounds except for devotional purposes.

8.

Lakes and dams are off limits except for scheduled authorized events. Swimming pool will be available only at scheduled times. I will follow all posted pool rules and instructions given.

I, X__________________________ agree to abide by this code and will pray for God’s will while I am at Summit Camps.

PARENTAL AND CAMPER SIGNATURES REQUIRED ON BACK OF FORM

Permission For Medical Treatment, Photograph/Video Notice, and Release and Indemnity My permission is granted for the camp or event Director, Church official, any camp or event staffer, or adult present or in charge of First Aid, to obtain necessary medical attention in case of sickness or injury to my child and also give permission to transport Camper to and from localities where such health services are provided. We have read or have had read to us the Summit Camps, and GLBA guidelines, rules and regulations. We agree that the below named camper will follow these rules while at Summit Camps at GLBA. We understand that Summit Camps and/or Grand Lake Baptist Assembly, is not the responsible party for the supervision of the campers, but it is the responsibility of the church bringing them to Summit Camps at the Grand Lake Baptist Assembly campground. Also, I understand that as a participant, my child may be photographed or videotaped during normal camp or event activities and these photos/videos may be used in promotional materials and on the web site. I, the undersigned, do hereby verify that the information provided is correct and I do hereby release and forever discharge Summit Camps or Grand Lake Baptist Assembly and their employees or staff from any and all claims, demands, actions or causes of action, past, present, or future arising out of any damage or injury while employed by or participating in this camp or event. I agree to indemnify Summit Camps or Grand Lake Baptist Assembly for any and all claims, demands, damages, injuries, costs, suits or causes of action, past, present, or future, arising out of or caused by my child while participating in this camp or event or while on property leased or owned by Summit Camps or Grand Lake Baptist Assembly.

Complete and sign below (Youth under 18 years of age requires Parent/Legal Guardian signature) Camper/Participant’s Signature ___________________________________

Date: ____________

Parent/Legal Guardian Signature __________________________________

Date _________________

Parent/Guardian Phone:

Cell Phone (_____)___________________

Home (_____)____________________________________ Work (_____)____________________________________

Summit Camp Student Profile Help us get to know you better by filling out this Student Profile. When you are finished, give this profile to the sponsors from your church attending Falls Creek, so they can know how to pray for you at camp. Name:

Grade This Fall:

Age:

City:

State:

Address: Phone Number:

Cell Phone Number:

E-mail Address:

Instagram: @

Zip:

Twitter: @

What activities are you involved in at school?

Tell us briefly about your family:

What is your favorite snack?

What is your favorite video game?

What is your favorite movie?

What is your favorite mobile game?

What is your favorite sport?

What is your favorite mobile app?

Does your family usually attend church? If yes, where?

Yes

No

Have you accepted Jesus Christ as your personal Lord and Savior?

Yes

No

Unsure

If you are a Christian, when did you accept Christ?

Were you baptized after you accepted Christ?

Yes

No

If yes, where?

Which of these have you done in the past week: (Check each one that applies.) Read the Bible Prayed Memorized a verse of the Bible Talked to someone about Jesus Have you ever attended Falls Creek?

Yes

Spent time alone with God

No

Why do you want to go to Falls Creek?

When the adults from our church pray for you, what would you like them to pray for during the week you are at Falls Creek?

47

Permission Slip Student Information Name_______________________________________________ Gender M / F DOB________________ Grade Your Student is going into this August: Pre-K

K

1st

2nd

3rd

4th

5th

Participation: We have been planning an amazing experience for your student and in consideration for the student’s participation

in ____________________________. I, for myself and on behalf of my attending student agree to release FBCS (First Baptist Church of Sapulpa), its officers, directors, and agents and anyone connected or associated with the church, from any liability for injuries to the student arising out of his/her participation, including during their transportation to and from the event as applicable. I also authorize FBCS to publish the photographs taken of me and/or the undersigned minor student and our names for any lawful purpose, including illustrations, advertising and web content. I release all claims against FBCS with respect to ownership and confirm that I am the parent or legal guardian of the minor student and have the authority to authorize use. Notice; FBCS will not be held liable for the loss of money or other personal items that may be lost or missing. Any damages or losses caused by my student, individually or with a group, shall become my responsibility. On all of our events, we have certain expectations of civil behavior which will insure that we all have a great experience. If, during this event, the student is unwilling to maintain these expectations, please understand that parents will be notified. Further, should it be necessary for the student to return home due to disciplinary action or otherwise, parents will assume all transportation costs.

Parent/Guardian Information Name______________________________________________Relationship__________________________________________ Address:_______________________________________________________________________________________________ Best Contact Number_________________________________Email________________________________________________ Emergency Phone: #1__________________________________ Emergency Phone: #2________________________________ Others Authorized to pick-up student:_______________________________________________________________________ (For your child’s safety a Photo ID may be required) Do you attend Church Y / N

Name of Church:_____________________________________________________________

Medical: My permission is granted for First Baptist Church of Sapulpa (FBCS) staff, sponsors, or chaperones to obtain necessary medical attention in case of sickness, injury, or accident to my student. This includes travel to and from the event/activity as well as the event/activity itself. I accept responsibility for any and all financial obligations incurred for such treatment. Food Allergies/Allergies/Medical Concerns:

Please list any medical concerns such as allergies, medications, etc. which pertains to your student: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Signature of parent or legal guardian Dated this _______ day of__________, 2015, Creek County, Oklahoma

X________________________________________ (Print Name)

X______________________________________ (Signature)

Optional: Do you have medical insurance? Yes! No! Insured’s Date of Birth / / Policy Holder__________________________________Policy #_______________________________

FIRST BAPTIST SAPULPA SCHOLARSHIP REQUEST FORM Students requesting scholarship funds must provide the following items: Name of Student: Age:

Grade Level:

Address:

Phone #: Email:

Event Name: Dates:

Total Cost: $

Amount of Total Able to Pay:

$

Amount of Scholarship Request:

$

Student Signature:

Date:

Parent Signature:

Date:

---------------------------------------------------------------------------------------------------------------------

For office use only Date Request Received:

Amount Granted: $

Signature: ________________________

Date Processed.:

Date of confirmation sent to requestor: