2021 Lake Lavon Family Day Registration

2021 FAMILY DAY REGISTRATION

Family Camp includes: 2 meals, recreation, worship, & fireworks.
Please provide as much information as you can. This information will help us to better serve you. If you have questions please don't hesitate to contact us.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
List first and last names and ages of adults attending: *
Older than 18 at time of camp
List first and last names and ages of youth between the ages of 12-18 years of age: *
Age at time of camp
List first and last names and ages of youth between the ages of 5-11 years of age: *
Age at time of camp
List first and last names and ages of youth between the ages of 0-4 years of age: *
Age at time of camp
Family Physician's Name *
Family Physician's Phone Number *
Please enter a valid phone number.
Insurance Provider *
Policy #
ID #
Emergency Contact Name *
Emergency Contact Phone Number *
In the following sections please list campers name and the appropriate information.

Food Allergies *
Non Food Allergies *
List recent illnesses, injuries, and hospitalizations relevant to above physician *
Current Medications, Dosage, Frequency / Times, Instructions *
ALL MEDICATIONS must be given to the Camp Nurse. Place medications in a large Ziploc bag labeled with camper's name. Prescriptions must be in the original container with the camper's name and current dosage clearly marked. No medications will be given unless they are in original containers per Texas Department of State Health Services. If your camper requires an asthma inhaler or antidote for insect bite or allergies (prescribed by doctor), please bring at least two (2) to camp. The medication must be registered with the Camp Nurse. One (1) will be kept and closely guarded by camper, and one (1) will be given to the Camp Nurse. Similar special cases must be discussed with the Camp Nurse.

By signing this document, you give permission for campers to be inspected for head/lice eggs, if the need arises. You understand that any such check would be conducted sensitively. You understand Lake Lavon Camp's Notice of Privacy Practices will use and disclose health information about your child/youth to group leaders, the child's sponsor, and designees, and any medical staff, when in its sole discretion believes such communication to be in the best interest of your child for treatment, to obtain payment for treatment, to evaluate the quality of care that he/she receives, and for administrative purposes. You agree to the release of any records necessary for treatment, referral, billing, or insurance purposes.
Signature *

Clear
Date *

Month Day Year

RISK RELEASE: In consideration of, and as part payment for the right to participate in Activities and the services and food arranged by Lake Lavon Camp & Conference Center, I (1) fully release Lake Lavon Camp from current or future liability from negligence, gross negligence, or intentional tort by any person, (2) assume all Risks and Dangers, whether or not that risk is foreseeable, and (3) will indemnify and hold Lake Lavon Camp harmless from any and all claims, liability, actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, for personal injury, property damage or loss, psychological injury or emotional distress, or medical expenses of any kind and attorney fees and costs of court filed by me or by other parties against Lake Lavon Camp, connected with my program or participation in any activities at or arranged by Lake Lavon Camp. I hereby agree that I will not sue Lake Lavon Camp & Conference Center for personal or property injury, and, if I attempt to sue, I will not collect any money. In addition, I will indemnify Lake Lavon Camp for attorney fees and costs of court fees associated with any litigation against Lake Lavon Camp connected with my program or participation in any activities at or arranged by Lake Lavon Camp & Conference Center.
REPRODUCED IMAGES: I authorize and release the use of my image to Lake Lavon Camp & Conference Cnter to be reproduced in any form including, but not limited to, photos, videos, magazines, newspaper, internet, and social media websites for any purpose of Lake Lavon Camp.
Lake Lavon Image Release *

Should be Empty:

2021 FAMILY DAY REGISTRATION