2016 YOUTH CAMP & RETREAT REGISTRATION FORM

CWMC Campers: Complete this form on both sides and mail to:

Attn: (name of camp), Community of Christ, P.O. BOX 60227, Renton WA 98058

CAMP SELECTION
SAMISH ISLAND: GENESIS MUNGAI KLUANE CHIMACUM KIMTAH
OTHER: Name/Date/Location of retreat/activity:
CAMPER AND CONTACT INFORMATION
Name:	Age:	Date of birth:	Male Female	High school graduate or Entering Grade:
Camper’s Home Phone:	Camper’s Cell Phone:	Camper’s Email:
Address:	City:	State/Province:	Zip:
Roommate Preference:
Religious Affiliation:	Home Church:
Name of Custodial Parent or Legal Guardian:	Name of Additional Parent, Legal Guardian or Next of Kin:
Work Phone:	Cell Phone:	Work Phone:	Cell Phone:
Parent Email:	Parent Email:
I hereby give permission for the following people, other than parents/guardians listed above, to pick up camper (please list):
EMERGENCY NOTIFICATION: These persons will be contacted if parents/guardians are not available.
Name 1:	Address:
City:	State/Province:	Zip:	Relationship:
Phone:	Email:
Name 2:	Address:
City:	State/Province:	Zip:	Relationship:
Phone:	Email:
CONSENT AND RELEASE
Photo Release: In consideration of the right of the aforementioned applicant to participate in this activity, I hereby give consent to and authorize the taking of photographs or videotapes in which the applicant may appear. I hereby waive all right of privacy in and to any said pictures or videotapes. Parent/Guardian Signature – I certify that I am submitting my signature electronically by typing my name:
Parent/Guardian Signature:	Date:
Activity Consent: I specifically consent to my applicant’s participation in activities offered by this camp, including, but not limited to, camping, boating, canoeing, swimming, hiking, body surfing and sporting activities. I have marked through any items from the preceding list to which I do not give consent for participation. I certify that my applicant has the necessary skills to participate in any of the approved activities. (If boating is approved, the camper can swim.) I specifically DO NOT want my applicant to participate in the following activities: Parent/Guardian Signature – I certify that I am submitting my signature electronically by typing my name:
Parent/Guardian Signature:	Date:
Transportation Consent: We understand that some activities involved in by this camp may require travel to other locations. All transportation during this youth camp will be provided by camp staff or people designated by them. All drivers of vehicles will be licensed and over the age of 21. We understand that most transportation will be in privately owned vehicles that are in good condition and considered safe. Parent/Guardian Signature – I certify that I am submitting my signature electronically by typing my name:
Parent/Guardian Signature:	Date:
Liability Release: The undersigned parent, legal guardian, next of kin, or participant acknowledges that even though every effort is made to provide a safe, accident-free environment, incidents may occur. In consideration for being accepted by Greater Pacific NW Mission Center, Community of Christ for participation in this event, we (I) being 21 years of age or older, do for ourselves (myself) (and on behalf of my child-participant, if said child is not 21 years of age or older) hereby release forever, discharge, and agree to hold harmless the aforementioned camp and Community of Christ and the directors thereof from any and all liability, claims, or damage for personal injury, illness, or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in this event. Furthermore, we (I) (and on behalf of our [my] child-participant if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreating and work activities involved therein. Further, authorization and permission is hereby given to said organization to furnish any necessary transportation, food, lodging for this participant. The undersigned further agrees to hold harmless and indemnify said organization, its directors, employees, and agents, for any liability sustained by said organization as the result of negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. Parent/Guardian Signature – I certify that I am submitting my signature electronically by typing my name:
Parent/Guardian Signature:	Date:

2016 YOUTH CAMP & RETREAT REGISTRATION FORM, pg.2

Camper Name:	Date of Birth:	Parent Phone:
CAMPER EXPECTATIONS
Attend the entire camp without interruption, unless the director and parent/legal guardian approves special circumstances. Live by the rules, schedules, and purposes of the camp. Live by the health, safety and property care rules of the campground. Leave all large electronics at home, and follow the rules for the use of smaller electronics as set by the camp director. Not possess or use tobacco products, marijuana, alcohol, or illegal drugs at camp. Be courteous and respectful of others and their property. This includes refraining from engaging in pranks, especially those that embarrass others and/or harm personal property or campground property. Use appropriate language that respects the worth of all people. Participate in work assignments. Dress in an appropriate way that maintains personal dignity and the dignity of others. Do your best to be a good camper and make the camp a positive experience for all campers and staff. I have shared these expectations with my child, and they commit to fulfilling them. I understand that failing to follow them may result in my child being sent home. If that happens, I will be responsible for immediately picking up my child from camp or making arrangements for this to occur in a timely manner. Parent/Guardian Signature – I certify that I am submitting my signature electronically by typing my name:
Parent/Guardian Signature:	Date:
HEALTH INFORMATION
General health condition: Excellent Good Fair Poor	Date of last tetanus vaccination:
Is camper currently under a physician’s care for any acute or chronic medical condition? Yes No If yes, please explain:
Personal physician:	Phone number:
Hospital/clinic of choice:
Health Insurance Provider:	Health Insurance Provider Phone:
Policy Holder’s Name:	Policy #:	Group #:
Does camper require prescription medications? (Include dosage instructions and any other helpful information.): Does camper carry non-prescription medication? (Please list medication(s) and purpose.): Are there any medications that should not be given? (Tylenol, throat lozenge, laxative, etc.):
Allergies - environmental, food or medicine (if none, please so state):
Special Dietary Restrictions (if none, please so state):
Camp Activity Restrictions: None Strenuous activities Swimming Other (describe):
Describe recent or major illnesses, injuries, surgeries, or exposure to contagious or infections disease (please include dates):
Girls: Has menstruation begun? Yes No If no, has she been told about it? Yes No
Does camper have any history of, or is he/she currently being treated for, the following: Anemia Appendicitis Arthritis Asthma Athlete’s Foot Bronchitis Diabetes Digestive disorder Epilepsy/seizures Fainting Fractures Heart condition Hepatitis Hernia High blood pressure HIV Hypoglycemia Kidney trouble Low blood pressure Nervous disorder Skin disease Skin ulcer Sore throats Tonsillitis Other: If yes to any of the above, please explain:
Please check any of the following conditions that apply to the camper: Homesickness Headaches Sleepwalking Cramps Toothaches Hearing problems Bed Wetting Stomachaches Earaches Swimmer’s ear Diarrhea Nosebleeds Vision problems Constipation Frequent Colds Fainting Recent emotional upset (death of loved one, divorce of parents, etc.); please explain:
Please describe any other medical, emotional, psychological, dietary or physical condition that could affect the applicant’s experience at camp:
Permission for Medical Treatment: I, the undersigned (parent or legal guardian), hereby authorize any necessary medical treatment for the applicant/myself. I also guarantee all payment of all charges incurred during this medical treatment. Parent/Guardian Signature – I certify that I am submitting my signature electronically by typing my name:
Parent/Guardian Signature:	Date: