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Student's Name

Date of Birth

Gender

Parent's / Guardian's Name

Mailing Address

Town/City

State

Home Telephone

Mobile

Work Telephone

Alt. Emergency Contact

Alt. Emergency Phone#

E-mail Address

Allergies

Current Health Problems or Disabilities

Medications currently taken

Date of Last Tetanus Shot (if possible)

Family Doctor

Family Doctor’s phone #:

Health Insurance Company

Policy #

Account #

Would You Like To Purchase A

Camp T-shirt for an extra $10?

What Size?

 

What to Bring:   Sleeping bag, or sheets and blanket, pillow, towels and washcloths, toiletries (soap, shampoo, toothbrush, DEODORANT, etc.) Bible, church clothes, activity clothes and snack money.

 

What NOT to Bring:  No weapons, water balloons or water guns, fireworks, electronic equipment, tobacco, or illegal drugs.

 

Dress Code for the Ladies:  Shorts, skirts, and dresses must be to the knees; loose fitting pants, loose fitting shirts.  Bring a swimsuit, shorts & T-Shirt to wear over swimsuit for water activities.   No shorts or pants during services. No sleeveless shirts permitted. (It may be cold so bring a coat.)  

 

Dress Code for the Men:   Shorts to the knees, long pants, shirts.  Bring swimming trunks & T-Shirt for water activities.  No shorts during services. No sleeveless shirts or mesh clothing. (It may be cold so bring a coat.)

 

 

ABSOLUTE RELEASE OF LIABILITY

 

MEDICAL AUTHORIZATION:   As the parent/guardian of this child, I  hereby certify that this child (named above) is in good health, free from all communicable diseases and able to participate in all event activities on and off campus. In case of medical and/or surgical emergency, I hereby authorize the Physician or Hospital selected by the camp administration to hospitalize, secure proper and appropriate treatment for, and/or order injection, anesthesia and/or surgery for my child (named above) as necessary and this authorization shall serve as a Limited Power of Attorney in accordance with the laws of the State of Arkansas in that regard.

 

In case of injury or illness, I understand that my primary insurance will be billed first and that the Arkansas District liability insurance will be billed as a secondary provider.

 

RELEASE OF ALL CLAIMS: With a full and intelligent understanding of my rights and privileges and the rights and privileges of my child named above, I hereby knowingly and designedly waive any and all claims in regard to the potential liability of the Pentecostal Church of God, its Boards, representatives, employees, camp personnel and agents.

 

PROPERTY LOSS: I further understand that the Pentecostal Church of God, its Boards, representatives, employees, camp personnel and agents are not responsible for lost, stolen, or damaged items belonging to the above named student. I assume full financial responsibility for any items damaged, destroyed or stolen by or from the above student. I

agree to pay transportation cost in the event the student must return home because of discipline or health reasons.

 

ACTIVITY RELEASE:  I give my child (named above) permission to participate in any and all activities, whether on or off campus.  I also give the Pentecostal Church of God permission to transport my child to said events, and will not hold them responsible for any accident or injury that may occur during these activities or during transportation to and from.

 

 

Winter Camp 2011 Online Application

As parent/guardian of this minor, I give my parental authorization and consent for my child to attend this event.

I have read the above Absolute Release of Liability Waiver and agree to all terms mentioned above.

Electronic Signature of Parent/Guardia (By typing your name in the box below and submitting this form, you are signing to affirm your agreement for you child to attend this camp, and to the Absolute Release of Liability terms above.

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