Summer Camp 2019 Registration – The Vision Church Pearland

ONLINE REGISTRATION FORM

PLEASE CLICK ON THIS LINK FOR CAMPERS PACKING LIST AND DRIVING DIRECTION

Exchanged Life Christian Camp Registration

2019 camp dates

Monday June 24 , 2018 – Friday June 28, 2018

Cost $130.00

2019 camp dates

Monday June 24 , 2018 – Friday June 28, 2019

ONLINE FORM BELOW

Camper Information

The Exchanged Life Christian Camp 2019 In order for your space to be reserved, a $30 non-refundable/non-transferable deposit must be received. To be eligible for a refund, not including the $30 deposit, cancellations must be made at least 4 weeks prior to the camp session. Total cost for each child including food, lodging and activities is $130.00. Ages 9-18 - LAST DAY TO REGISTER IS 06/10/2019 CAMP DATES June 24,2019– June 28, 2019 Camp Location: 14011 CR 602 Danbury, TX 77534
Camper's First Name
Camper's Last Name
Gender
Choose OneMaleFemale
Age
Camper's T-Shirt Size *

Camper would like to bunk with these two friends:

1st Friend's First Name
2nd Friend's Last Name
1st Friend's First Name
2nd Friend's First Name

Parent Information

Father's First Name
Father's Last Name
Mother's First Name
Mother's Last
This camper lives with:
Both ParentsFatherMother
Legal Guardian: (name)

Contact Info

Home Phone
Father's Cell Phone Number
Father's Work Phone Number
Mother's Cell Phone Number
Mother's Work Phone Number
Email
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Emergency Information

Name of Family Physician
Physician Phone
Do you carry family medical/hospital insurance?
Carrier Name
Carrier Phone
Group Policy Number
Name of Policy Holder

Secondary Emergency Contact

In the case of an emergency, Our staff will contact the parent or legal guardian immediately. If we are unable to reach you, please list a secondary contact person whom we can call. This contact person must be someone not living in the same household, otherwise your group leader will automatically be the designated emergency contact person.
Name
Relationship
Day Phone
Evening Phone

Medical Information

Medical Conditions Due to the nature of activities at The Vision Church , full disclosure concerning the camper's medical history must be made. If full disclosure is not made in advance, the Camp Director will be forced to refuse the camper, and the parents will be forced to pick up the camper immediately. Campers who arrive with fever, ringworm, pink eye, or any other communicable disease or undisclosed handicap or disability will not be admitted.
Does this camper have asthma?
Has this camper ever had convulsions?
Does this camper have diabetes?
Does this camper have a heart defect?
Does this camper have any other medical conditions or diseases?
Please describe
Medications Does this camper take any prescription medications?
yesno
If yes, please list:
Is this camper allergic to any medications?
Is this camper allergic to peanuts?Is this camper allergic to red dye?Is this camper lactose intolerant?Does this camper have allergies? (food, animals, insects, etc.)
Any other details ?
Limitations
Does this camper have physical limitations?
Has this camper had psychiatric treatment?
Does this camper have mental limitations?
Are there any activities from which this camper should be restricted?
Other Details
Are immunizations current for this camper?
Does this camper have any difficulty with bed wetting?
Is there any additional information regarding this camper that you feel might be helpful

Adult Participant or Parent/Guardian Signature

As the parent or legal guardian of the Camper, I authorize Camper to attend Camp and to engage in all Camp activities, including water sports, outdoor activities, and strenuous activities. I agree, personally and on behalf of Minor to release The Vision Church , and their representatives and employees (collectively), from all liability for harm to Minor or Minor's personal property. I authorize administration of a tetanus shot or other medical treatment deemed necessary by The Vision Church and I agree to release and indemnify The Vision Church against all liability and costs for treatment. I also authorize The Vision Church to use photos or video taken of Camper for promotional and recordkeeping purposes.
First Name *
Last Name *
Date

Participation Agreement & Waiver

Name of Camp Participant I am above the age of 18 and am signing this agreement as the camp parent/legal guardian.
I, parent/legal guardian
, am the parent/legal guardian of the came participant, a minor. Name of camper

This form must be signed by the camper's legal guardian.

I hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child my permission to attend The Exchange Life Camp. Furthermore, I consent to give my child permission to participate in all activities including, but not limited to, climbing, repelling, low rope elements, high rope elements, swimming, other water activities, and all indoor and outdoor events and activities. I understand all activities are optional and that my child or I have voluntarily applied to participate in the events and activities of the Camp. I understand the foregoing activities and all other events, hazards or exposures connected with the Camp and the indoor and/or outdoor activities, involve risk of harm and that accidents or illness can occur in places without medical facilities, physicians, or surgeons. I am aware of the risks and damages inherent with those activities and I knowingly and willingly assume the risk of injury. Authorization for Emergency Medical Treatment I have listed above my or my child’s physical conditions or medical problems that may need attention and all medications regularly used by myself or said minor. I understand failure to disclose medical information/condition may result in dismissal from The Exchange Life Camp. In case of the illness of myself or my child, The Exchange Life Camp will try to notify whoever is listed as the emergency contact person. In the event there arises a medical emergency concerning myself or my child, at a time where the emergency contact cannot be notified, I authorize The Exchange Life Camp to consent to any necessary X-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care. I hereby consent and give my permission to the The Exchange Life Camp Vision Church staff or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon myself or my child that may, in their sole discretion, be necessary and proper under the circumstances. General Release and Waiver of Liability I DO RELEASE, ACQUIT, DISCHARGE, AND COVENANT TO HOLD HARMLESS THE EXCHANGE LIFE CAMP STAFF, PERSONNEL, OR ANY OF ITS REPRESENTATIVES FROM ANY ACTIONS, DAMAGES, OR LIABILITIES ARISING OUT OF ANY INJURIES OR PROPERTY DAMAGE SUSTAINED DURING THE PARTICIPATION IN THE CAMP AND/OR RESULTING FROM THE TREATMENT OF ANY ILLNESS, SICKNESS, OR ACCIDENT, INCURRED BY MYSELF OR MY CHILD DURING HIS/HER STAY AT THE EXCHANGE LIFE CAMP. In consideration for being permitted to attend The Exchange Life Camp and participate in the activities conducted by the Camp, I, on behalf of myself, my child, my legal representatives, heirs and assigns, do hereby release, waive, and forever discharge The Exchange Life Camp and its officers, employees, volunteers, and agents, of and from any and all loss, damage, claim, demand, action or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident that may occur as a result of my or my child’s participation in the camp activities or any activities in connection with the The Exchange Life Camp Vision Church, whether by negligence or not. I, personally, and on behalf of my child (if child is the camp participant), hereby give Exchange Life Camp Vision Church permission to use my and/or my child’s name, photograph, quotations and likeness in any advertisements or promotions performed in connection with the camp and agree that neither I nor my child shall be entitled to any compensation for such use. I agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that if any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Adult Participant or Parent/Guardian Signature

First Name *
Last Name *
Date

Verification

21 *Example: 21
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DIRECTIONS TO EXCHANGE LIFE SUMMER CAMP

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