2023 JESUS CAMP - CAMPERS APPLICATION AND MEDICAL RELEASE FORM

ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT

AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR AGREEMENT

MEDICATION AUTHORIZATION AND RELEASE AGREEMENT

Application must completed and submitted by parent/guardian only!

Cell phones are not allowed. If the cell phones are brought, they will be stored by camp director. We are not responsible for any damage to cell phone.

You will need to bring money if you want to eat at the concession stand

Full Name of Applicant*

First Name Middle Name Last Name

Date of Birth *

MonthDay Year

Camper Email*

Parent or Guardian *

First Name Middle Name Last Name

Parent or Guardian Email*

Parent Phone Number*

Area Code Phone Number

Parent Mobile Phone Number*

Area Code Phone Number

Gender*

MaleFemale

Current Age*

Grade for 2021-2022*

Street Address*

Street Address

City, State, Zip*

Emergency Contact Name*

Emergency Contact Phone*

2nd Emergency Contact Name*

2nd Emergency Contact Phone*

Choose one:*

I have never attended Jesus CampI have attended Jesus Camp in the past

How did you hear about Jesus Camp?

Is there anything you would like to share about yourself?

T-Shirt Size*

What church do you presently attend?

Does applicant have any allergies to prescription drugs or non-prescription drugs?*

NoYes

If yes, please describe:*

Does applicant have any food allergies?*

NoYes

If yes, please describe:*

Does applicant have an inhaler? Note: Two inhalers should be brought to camp.*

NoYes

Do you take any medications?*

NoYes

If yes, please list the medication, reason for taking, and any side effects you may experience:*

Special note about medication:

Please note that if applicant will be bringing ANY medications to camp, including all prescription, over-the-counter and herbal remedies, the following rules will need to be followed:

1. All medications must be in their original packages. i.e. prescriptions in the prescription bottle, Tylenol in the Tylenol bottle, herbs in the bottle that they were originally bought in.

2. All medications must be accompanied by written and signed instructions for administration (the prescription on the bottle will be fine unless doses or times have changed).

3. Any nonprescription bottles must have the applicants name written on them and prescription bottles must be for the applicant. PLEASE help us to take good care of the precious and wonderful children that you have entrusted to us!

Had any recent injury, illness or infectious disease?*

YesNo

If yes, please explain.*

Have you had any serious illness, injuries, or medical operations in the last three years?*

YesNo

If yes, please explain.*

Ever passed out during or after exercise?*

YesNo

Ever had high blood pressure?*

YesNo

Ever have dizziness or chest pains after exercise?*

YesNo

Have a chronic or recurring illness/condition?*

YesNo

Ever had frequent ear infections?*

YesNo

Have problems with sleepwalking?*

YesNo

Ever have seizures?*

YesNo

Have diabetes?*

YesNo

Have asthma?*

YesNo

Ever had emotional or mental difficulties for which professional help was sought?*

YesNo

If yes, please list:*

Insurance Company*

Policy Holder's Name *

First Name Last Name

Policy Holder's Date of Birth *

Date

Policy or Group Number *

Policy Holder Insurance ID#:*

Insurance Phone Number*

Insurance Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT

AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR AGREEMENT

MEDICATION AUTHORIZATION AND RELEASE AGREEMENT

WHEREAS, THE UNDERSIGNED (the applicant) wishes to be accepted for participation in all activities conducted by GOD IS GOOD MINISTRIES OF DALLAS, INC. (hereafter called “GIG”). In consideration of, and for the right to participate in such activity by GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associate, I have and do hereby assume all of the risks and any other ordinary risk incidental to the nature of the activity.

Further I will hold GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associate harmless from any and all liability, actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss, medical bills, hospital bills, and doctor bills, or otherwise, which the participant now has or which may arise from or in connection with participation in any activities arranged for me by GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associates, and their heirs, executors, and administrators, successors and assigns and for all members of my family, including any minors accompanying me. I fully understand that my physical activity involves risk of injury. I also understand that my participation in any activity is entirely VOLUNTARY. I enter into this activity and take full responsibility for the decision to participate or not to participate and agree to follow all safety instructions.

I do hereby release GIG, its Directors, Officers, Trustees, Employees, Agents, and/or Associate any liability whatsoever (including acts of negligence) arising out of an injury, damage, death, or loss, whether physical, mental or emotional, which may be sustained to the applicant, during the course of applicant’s involvement with this camp or any overnight camping before the camp session or after the camp session. I consent to the use and display of photographs (possibly on the internet) of the applicant.

I hereby agree that all health history is correct and complete as far as I know and the person herein described has permission to engage in all camp activities except as noted. I understand that applicant may be sent home if Camp rules are not followed.

Medications: I give permission to camp staff to administer "over-the-counter" medications and/or prescription medications (listed above, or prescribed during camp) to the applicant. I give authority and consent for GIG to treat applicant for a headache, fever, or upset stomach with the appropriate non-prescription medication such as Ibuprofen, Acetaminophen and Pepto-Bismol.

Emergency Medical Authorization: I consent for emergency medical treatment to be administered to the applicant by a licensed Physician, Nurse, Adult Staff Member or other emergency medical personnel. I hereby give permission to medical personnel to order X-rays, routine tests, and treatment for applicant. I hereby give permission to the Physician to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery. I hereby authorize transportation to a medical facility by ambulance or other transportation if it is deemed necessary.

Application Approval *

I understand that my signature on this form constitutes a legal digital signature approving application. I understand that I must be a parent or legal guardian if I'm signing for a child under the age of 18. I have read this application and approve. By signing below, I hereby agree to the "ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT, AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR AGREEMENT, MEDICATION AUTHORIZATION AND RELEASE AGREEMENT" including all statements listed on this application.

THE SIGNATURE, DRIVER'S LICENSE NUMBER OR SOCIAL SECURITY NUMBER MUST BE COMPLETED AND SIGNED BY PARENT OR GUARDIAN.

Driver's License # or State ID # and State*

Today's Date*

Parent or Guardian Signature (Note: Sign document with computer mouse or using your finger on a phone)*

Printed Signature Name*

Enter the message as it's shown.*

GOD IS GOOD MINISTRIES OF DALLAS

Medical History