* A COPY OF THE CAMPER'S IMMUNIZATION RECORD MUST BE MAILED TO THE CAMP OFFICE AT LEAST 7 DAYS PRIOR TO YOUR CAMP SESSION.
Please fill in the following information as completely and accurately as possible. Any medication that the camper is currently using along with information describing dosages, frequency, and other instructions concerning medication or any treatment must be turned in to the camp nurse upon arrival at camp.
List any medication that will be taken at camp.
Please include detailed instructions and other
pertinent information regarding the reasons for this
medication.
Are there any activities encouraged or limited by a physician?
Health History - Please Check All That Apply
Frequent ear infections
Bleeding or clotting disorder
Heart defect/ disease
Dizziness/ fainting
Chest pains
Epilepsy
Mononucleosis
Arthritis/ joint problems
Diabetes
Hypertension
Back problems
Pregnant
Operations or injuries
Allergies - Please check all that apply
5. Insurance Information
Physician Name
Physician Phone
Insurance Company
Policy or Group #
Insurance Phone
Insurance Address
City
State
Zip
Emergency Contact
Relationship
Emergency Contact Telephone Number
7. Agreement to Participate, Assumption of Risk and Release of Liability
I (we) acknowledge that during the session that the applicant is participating in, certain risks and danger may occur. I (we) recognize that such risks and danger may include loss or damage to personal property, physical injury, or fatality due to accident. I am healthy (both physically and emotionally) and capable of participating in this session. The health history is correct as far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. I fully authorize the camp's medical personnel to order x-rays, routine tests, treatment and necessary transportation for me/ my child. In the event the parent or guardian cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for me/ my child as deemed necessary.
I, individually and on behalf of the minor, do hereby release, Victory Camp (a ministry of Living Stones Church) and its employees from any and all liability, INCLUDING, BUT NOT LIMITED TO, THE NEGLIGENCE OF VICTORY CAMP AND IT'S EMPLOYEES. I also understand that my participation in this Victory Camp program is entirely VOLUNTARY. I enter into this session and take full resposibility for my decision to participate or not to participate and agree to follow all safety instructions. I understand that photographs or video may be taken of me/ my child during the session for promotional use by Victory Camp. I understand that I will not receive compensation, monetary or otherwise in exchange for these images. I agree that being allowed to participate in Victory Camp is sufficient consideration to support this agreement to participate.
You must complete a separate form for each child you are registering.
By checking the "I Accept" box you are agreeing to the information included in the Agreement to Participate, Assumption of Risk, and Release of Liability statement. According to the Electronic Sgnature Act of 2001, accepting this statement is equivalent to your legal signature. Do not accept this statement unless you are the parent or legal guardian of the camper that is being registered or are over 18 years of age.
Age
Gender
Any special requirements or attention needed (please explain):
Dietary restrictions:
The proposed activities provided by Victory Camp require participation in physical exercises which are by their nature physically demanding. Many of the activities, inlcuding, but not limited to, challenge course activities, soccer, go-karts, basketball, volleyball, etc., will or may challenge you, and could cause surges in blood pressure and pulse rates. It is imperative that you are free from any heart-related or other diseases. Therefore, all participants must be free of medical or physical conditions which might create undue risks to themselves or any others who depend on them. If there is any doubt about your ability to sefely participate in this experience, you should receive a physical examination. If you check any of the inquired conditions, it is soley your responsibility to receive the necessary approval from the appropriate health care providers for your participation in all physical activities. if more information is needed regarding such activities, please contact Victory Camp.
If yes, please explain (include date)
6. Payment Information
Please indicate your payment method:
Credit card payments must be processes online through PayPal. There is a $25.00 fee for returned checks. All payments must be comlpete at least 7 days prior to your camp session.
Registration information and payments must be made prior to the early bird deadline to qualify for the early bird discount.
You will be directed to the payment page upon completion of this form.
