SALCA Form

Each camp is geared for the appropriate aged youth. Camp activities include music, sports, Bible study, hiking, arts and crafts, food, friends and fun.

If your youth has special needs, please contact the registrar ahead of time and make a note in the medical section of this form.

Camper Information

Camper's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade (completed by May 2022) *

Gender *

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Church *

Registration includes a camp t-shirt. Please indicate size. *

Youth Small Youth Medium Youth Large Youth Extra Large Adult Small Adult Medium Adult Large

Roommate Request

Please request only one person. That person should also request you. There is no guarantee that this request can be fulfilled.

Roommate Name

Roommate Home Church

Parent/Guardian Information

Name *

First Name Last Name

Home Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name (other than parent/guardian) *

First Name Last Name

Relationship

Phone Number *

Area Code Phone Number

Alt. Phone Number *

Area Code Phone Number

Medical Insurance Company *

Insurance Policy Number *

Is this your child's first time away from home or to a sleepover camp? *

Yes No

What comforts your child if he or she is distressed? *

Does your child have any known drug or environmental (i.e. bees, ants, etc.) allergies? *

Yes No

If yes, please explain and note usual treatment.

Does your child have any physical, medical, or behavioral health concerns? (such as ADHD, anxiety, depression) *

Yes No

If yes, please explain. (all information will remain confidential)

List all daily medications, including any medications taken as needed. Please list the purpose of the medication, the dosage, and the times given.

Please list any special dietary needs or food allergies.

Is your child vaccinated against COVID-19? *

Yes No

Has your child ever tested positive for COVID-19? *

Yes No

If yes, when?

Has your child been exposed to someone who tested positive for COVID-19 *

Yes No

Has your child experienced any cough, fever, runny nose, sore throat, headache, nausea, or vomiting in the past 10 days? *

Yes No

Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the Dean of Camp, or the Dean’s adult appointee, as agents for the undersigned, to consent to any examination, anesthetic, medical or surgical diagnosis and/or treatment and hospital care which is deemed advisable by, and is rendered under the general or specific supervision of any surgeon or physician who is licensed under the provisions of the Medical Practice Act and is on the medical staff of any accredited hospital. It is understood this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of my/our aforesaid agents to give special consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is further understood that all effort will be made to contact the parent(s) or legal guardian prior to the use of this authorization.

I do hereby authorize the SALCA Camp Nurse, or other designated SALCA representative to perform any necessary minor first aid procedures and dispense medications as deemed appropriate unless specifically forbidden by me/us in writing.

I agree to release and hold harmless the SALCA Camp Nurse or other designated SALCA representative from any liability arising from my child treatment.

This authorization shall remain effective from May 30, 2022 - June 3, 2022 for SALCA summer camp; unless revoked in writing and delivered to said agents.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

I agree to the Medical Release and Authorization. *

Yes

Photo/Video Release

I give The Southern Arizona Lutheran Camping Association permission to photograph, interview, or video tape my child; and give permission to use my child’s photograph on the SALCA website, as well as other social media sites.

I understand that photographs, interviews, and/or video tapes may be used for public viewing (including but not exclusive to church programs, slide shows, presentations by SALCA staff at conferences or workshops, SALCA website and SALCA social media sites).

In giving my permission to use my child’s photograph, I understand that NO CHILD’S NAME OR OTHER IDENTIFYING INFORMATION WILL BE PLACED ON THE SITE WITH HIS/HER PICTURE.

I agree to my child’s participation, without financial compensation, and I understand that this releases any claims against Triangle Y Ranch Camp, any SALCA employees and its photographers from any future claims, as well as any liability arising from the use of said photograph/interview/video tapes or portions thereof used for public viewing.

I agree to this Photo/Video Release statement. *

Yes No, and I request my child's picture does not appear on the SALCA website or be published in any format

Registration Fee

The Registration Fee for camp is $275 and due by May 30, 2022. Scholarships are available on an as needed basis. Requests for scholarships must be accompanied by the SALCA Scholarship Form.

The minimum deposit of $75 is non-refundable after May 15, 2022. The remainder of the Registration Fee is payable no later than camp check-in on May 30, 2022.

You may mail a check to:

SALCA c/o Christ Lutheran Vail Church

14600 E Colossal Cave Road

Vail, AZ 85641

Or you may pay online at: www.mysalca.com

The camp management and SALCA staff expect that the registrant will be able to abide by camp rules and policies or he/she will be sent home at the parent's expense.

Camp information, rules, what to bring, and the camp scholarship form can be found at www.mysalca.com.

Confirmation

BY CHECKING 'YES' TO THE 'I AGREE' BOX AND ENTERING MY FULL NAME I RECOGNIZE I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AND WILL BE AS EQUALLY BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

I Agree: *

Yes No

Name *

First Name Last Name

Date *

Date

SALCA Summer Camp Registration

Elementary and Middle School Camp | May 30 - June 3