2023 Preteen 3 Registration Form

Please select the Church you are attending camp with:*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Gender*

Date of Birth*

Date

T-shirt Size*

Drivers License # and State of Issue, if camper is under the age of 18 please put N/A.*

Emergency Contact*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Physician's Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Insurance Provider*

Policy #*

ID #*

Age*

Height*

Weight*

Have Special Dietary Needs?

We strive to accommodate all of our guests, however, due to volume of guests that
we serve, our ability to accommodate special dietary needs is limited. We are able
to provide gluten-free, dairy-free and vegetarian options when given prior notice
(at least 7 days).
We are aware that peanut allergies are airborne. If you have a SEVERE peanut
allergy, please let us know.
In cases where we are not able to accommodate, we invite you to bring your own
food and we will provide storage, refrigeration and access to a microwave.

Food Allergies*

Non Food Allergies*

List any recent illnesses, injuries, and hospitalizations*

List any current medications*

Are your immunizations up to date?*

Are you allergic to the Tetanus Booster?*

Date of last Tetanus Shot*

Date

I hereby authorize Lake Lavon Camp staff, camp nurse, or group leader to make emergency medical decisions for the camper. I understand my personal insurance coverage will be the primary coverage. *

Please Initial (Parent/Guardian initial if under 18)

I hereby authorize Lake Lavon Camp staff, camp nurse, or group leader to dispense over the counter medications as deemed necessary without my notification.*

I prefer that in the case of over the counter medicine, the camper be given:*

ALL MEDICATIONS must be given to the Camp Nurse. Place medications in a large Ziploc bag labeled with camper's name and church name. Prescriptions must be in the original container with the camper's name and the current dosage clearly marked. No medications will be given unless they are in original containers per Texas Department of State Health Services. If the 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 the camper 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 the camper 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 the camper 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.

All campers should monitor their health and not come to camp if they exhibit any symptoms of COVID-19 or any other seriously contagious sickness. We are implementing multiple safety measures to care for everyone that attends Lake Lavon Camp but there is an inherent risk during these times. Please understand that attending camp carries a risk and is a choice.

Signature (Parent/Guardian signature if camper is under 18)*

Clear

AUTHORIZATION FOR BACKGROUND CHECK (18 years or older): In consideration of the receipt and evaluation of this form by Lake Lavon Camp & Conference Center located at 8050 CR 735, Princeton TX 75407, I hereby give my permission to obtain information relating to my criminal history record. I understand that this information will be used, in part, to determine my eligibility to serve at Lake Lavon Camp. I hereby release any individual, church, youth organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or my family, on account of compliance or any attempts to comply with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me on this screening form. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification if I dispute the record as received. I agree to be bound by the constitution and policies of Lake Lavon Camp & Conference Center and to refrain from non-scriptural conduct in the performance of my services on behalf of the Camp. The basic criteria which have been established by the State of Texas for conducting youth camps is met or exceeded by Lavon Camp Group Leader Handbook requirements, and I agree to read thoroughly and adhere to all guidelines therein.

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 Center to be reproduced in any form including, but not limited to, photos, videos, magazines, newspapers, Internet, and social media websites for any purpose of Lake Lavon Camp.

By my signature below, I verify that I have read and understood all provisions of this agreement. (If camper is under 18, must be signed by parent/guardian)*

Clear

Date*

Date

Printed Name*

First NameLast Name

2023 Preteen Session 3

Camp Attendee Information

Medical Information

Authorizations and Releases