Youth Summer Camp 2014

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Medical Information ALLERGIES: _____________________________________________________________________________ (food or medications) IMMUNIZATIONS Current?: Yes No If No, please explain: __________________________________________________________________________________________________ Last Tetanus Shot:: ______________________________ MEDICAL PROBLEMS or RECENT ILLNESS? (Please describe): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ MEDICATIONS: Please list ALL medications taken, prescription and over the counter. Use separate piece of paper if needed) Reason ______________________________

Schedule _______________________

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Yes

No

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Yes

No

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Yes

No

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Yes

No

Benadryl Yes

So we say with confidence, “The Lord is my helper; I will not be afraid. What can man do to me?” - Hebrews 13:6

Will youth have this med at camp? Yes No

NAME of medication ________________________

Do you give permission for the camp nurse to administer: Tylenol Yes No Ibuprofen/Advil Yes No

Youth Summer Camp 2014

No

Is your youth able to participate in all recreational activities? If NO, please explain: _________________________________________________________________________ IN CASE OF AN EMERGENCY, NOTIFY: Name: ___________ Home Phone: __________________________ Health Insurance Agency:

Cell: _____________________________ ____

July 24, 2014

Release of Liability and Claims

(camper’s name) has my permission to engage in prescribed activities, except as noted by me. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by an adult leader in charge, to order injection, surgery or any other medical treatment that may be deemed necessary to insure the well-being of the above named, due to sickness or accident while attending Youth Camp at Lakeview Conference Center in Waxahachie, Texas or en route to or from the encampment. I also authorize the camp personnel or adult counselors to transport my child at their discretion in case of an emergency. We represent to you that we and the participant hold the camp, its agents, employees and representatives and First United Methodist Church of Carrollton, its agents, employees and representatives members, agents and volunteer camp workers from any and all liability, claims, damages, losses, and causes of action of whatever kind, arising directly or indirectly from or during my child’s participation in camp activities, be they formal or informal, and/or from my child’s transportation to and from such activities, and (2) to maintain at my own expense adequate medical and hospitalization insurance coverage for said child, and (3) to bear sole financial responsibility for all injuries, medical care and other costs relating to my child arising from any accident at or during any camp activities, including transportation provided to or from such activities.

Youth will be meeting at church on Thursday night to rally together and get pumped up for camp! Plan to spend the night, enjoy snacks, and fellowship with one another before heading out for camp on Friday.

July 25-28, 2014 Lakeview Conference Center Waxahachie, Texas

Parents’/Guardians’ Signature: ___________________________________________________ Print full name:

Date: _____________________________

*my signature also gives my permission for my youth to appear in any photos or videos made at the camp for future promotion of Youth Camp.

First United Methodist Church Carrollton 2201 E. Hebron Parkway | Carrollton, TX 75010 469.568.1240 | firstchurch.net

Registration Form:

Camp is open to any youth who will be entering seventh grade through graduating seniors. Cost for Camp: $275 for your first teen and $210 for each additional sibling. This includes meals, lodging, all recreation and camp t-shirt! If you need to pay in installments, you can do so as long as the entire fee is paid in full by camp time.

Complete both sides of the Registration Form. Detach and mail your payment to: First United Methodist Church Carrollton 2201 E. Hebron Parkway | Carrollton, TX 75010 469.568.1240

Bring to Camp:

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Bible, journal, pen/pencil Flashlight Money for snack bar Pillow, towel, and washcloth Casual clothes for 4 days Clothes that can get dirty for rec Dirty clothes bag Swimming suit and towel (Girls, one piece) Sheets/blanket for twin bed or sleeping bag Personal care items (soap, toothbrush, toothpaste, deodorant, comb, etc.) Clothing/props for your team spirit

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cell phones Electronic games or iPod Knives or sharp objects Fire works of any kind Bad attitude Stuff for pranks

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Do Not Bring:

PLEASE PRINT

Camper’s Name:

Goes by:

Address: Sex:

City, Zip: Grade entering:

Birthdate:

Phone:

Parent’s or Legal Guardian’s Name: Parent’s Cell Phone:

Parent’s E-mail:

T-Shirt size (included in registration) Circle size needed: Adult-S Adult-M

Adult-L

AMOUNT ENCLOSED: $275.00

Adult-XL

Adult-XXL

Adult-XXXL

(For first teen) $210_______ (for each additional teen)

Payment Type: Check/Cash______ Youth Account________ Paid Online________ A $10 fee will be added per child if registered after July 2nd Make checks payable to First Church Carrollton.

(Office use only) Date Received:

Amt. Pd:

Chk No: