2018 Forever His Luau Registration

Camp Registration Form
- Our Fall Camp, for Age 12 years and under, is on Saturday, September 14th, 2024. The deadline to register is September 7th.
- Our Spring Camp, for Age 13 years and up, will be Saturday, April 12, 2025.
- Doors open at 9:30 a.m. Activities begin at 10:15 a.m. and go through 2:30 p.m.
  It will be held at Karns Church of Christ, 6612 Beaver Ridge Road, Knoxville, TN 37931.
  
  Your child must be pre-registered first. (See below).
ACTIVITIES:

Songs, crafts, games, puppets, scavenger hunt, story time, karaoke, black light room, and live animals.

CARE OF YOUR CHILD:
- Each “Forever His” guest will have “buddies” who will help them participate to the fullest.
- We have given special consideration and prepared for each guest’s safety, medical needs, food sensitivities, bathroom/diapering needs, and mobility and sensory issues. We want to be prepared for whatever need our guests may have. Included in our staff will be a physician, registered nurses, therapists, special education teachers along with a host of other volunteers.
- A detailed registration form (see below) must be completed in advance so we can adequately prepare.
FOR QUESTIONS, CONTACT:
- The Karns church at 865-691-7411 or email Kim Higginbotham at higginbotham.kim@gmail.com.
We will be in contact with you closer to the event to make sure all your questions are answered! Thank you for registering your child!

Kim Higginbotham
Student Information
Student Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Church:
Gender*

MaleFemale
Date of Birth (MM/DD/YY)*
Primary Physician's Name*
Physician's Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medical Insurance Company*
Policy #*
Chronological Age*
Developmental Age*
Diagnosis*
Current educational setting or daytime activities*
Drug allergies (Type "none" if there are none.)*
Food or Other Allergies (Type "none" if there are none.)*
Nutrition/Dietary Information
Dietary Needs (Check all that apply)*

Can feed self without assistanceHas difficulty chewing or swallowingNeeds soft foodNeeds food cut into small piecesHas feeding tube (elaborate below)
Dietary: Any other special instructions
Toileting & Hygiene Information
Toilet & Hygiene*

IndependentNeeds supervisionWears diaper or Pull-upHygiene assistant (wiping, washing hands)Physical assist to transfer to toiletHas an ostomy (elaborate below)
Toilet & Hygiene: Any other special instructions
Mobility Information
Mobility*

IndependentPower chairWheelchairStrollerWalkerCrutchesService dogAdult hand-held assistance
Mobility: Any other special instructions
Health & Safety Information
Seizures*

Yes (elaborate below)No
Seizures: Special instructions and details*
If child does not have seizures, put "none" in this field
Other health issues*
List any medications your child is currently taking (If none, type "none")*
Attitudes and Behaviors*
How can we redirect inappropriate behaviors?*
How does your child react to people he/she does not know?*
What type of reward system is used with your child?*
Communication
Does your child use verbal or nonverbal communication?*

VerbalNonverbal
Does your child read?*

YesNo
Does your child write?*

YesNo
Does your child use sign language?*

YesNo
Is your child's speech understandable?*

YesNo
Can your child communicate his/her basic needs?*

YesNo
Any other information we need to effectively communicate with your child:*
Sensory & Physical Information
Does your child have any sensory processing issues? If so, please explain.*
Does your child have any physical limitations? If so, please explain.*
What type of physical apparatus/equipment does your child use, if any?*
Additional Information
T-shirt Size*

Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult Extra LargeAdult 2X
"You didn't ask, but I want you to know this too..."*
Family & Emergency Contact Information
Parent/Guardian Name #1*
Relationship to Child*

FatherMotherGuardian
Home Phone*
Parent/Guardian Cell Phone*
E-mail
example@example.com
Parent/Guardian Name #2*
Relationship to Child*

FatherMotherGuardianOther
Parent/Guardian Cell Phone*
E-mail
example@example.com
Consents and Releases

IMPORTANT! Please read and sign your name below to give consent to the following:
- I/we have disclosed to Karns Church of Christ all pertinent facts and medical conditions about my child's special needs and accept full responsibility for failure to do so.
- If my child shows ANY symptoms of illness within the previous 24 hours, I/we will not leave him/her in the care of Karns Church of Christ. If my child shows ANY symptoms of illness while in the care of Karns Church, I understand I will be called and asked to pick up my child.
- I/we give permission to Karns Church of Christ to share this information with the volunteers & staff.
- In case of emergency or accident, I or my other listed contact person will be called immediately. If necessary, 911 will be called.
- I/we the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend this Forever His event organized by the Karns Church of Christ.
- I/we understand that there are inherent risks involved in any ministry or event, and I/we hereby release the Church, its ministers, adults, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.
- I/we also hereby release, absolve, indemnify, hold harmless, and forever discharge the church, elders, ministers, deacons, organizers, volunteers, chaperones, and supervisors from any and all claims, demands, actions, or cause of actions present, past or future should my child contract Covid-19 while participating in this event.
- I/we also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider or if I/we do not carry any health insurance.
- Further, I/we affirm that the health insurance information provided above, if applicable, is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above.
- I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Karns Church of Christ staff or its volunteers.
Consents & Medical Release Signature*

Clear
(Sign with your finger or curser)
Photo and Video Release

I hereby assign and grant to the Karns Church of Christ permission to use and publish the photographs and video recordings taken of my child during this Forever His event for use in the Karns Church of Christ printed publications, audio/visual media, social media and the church website. I hereby release the Karns Church of Christ from any and all liability from such use and publication. By signing below, I acknowledge I have read and understand all information about the Photo and Video release statement.
Photo & Video Release Signature

Clear
(Sign with your finger or curser)
How Did You Hear About the "Forever His" Ministry?
Briefly describe how you heard about us:
Should be Empty:

Camp Registration Form

ACTIVITIES:

CARE OF YOUR CHILD:

FOR QUESTIONS, CONTACT: