Camp Wilmot 2023 Registration Form

Church Information

Please fill out this section if you attend a church at home. This may not be applicable for all staff.
Name of Home Church:
Denomination of Home Church:
Address of Home Church:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for Home Church:

Area CodePhone Number

Emergency Contact Information
Contact #1
Name:*

First NameLast Name
Relationship to the Staff Member:*
Email Address:*
example@example.com
Phone Number:*

Area CodePhone Number
Type of Phone:*
Contact #2
Name*

First NameLast Name
Relationship to the Staff Member*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Type of Phone*

Diet, Activity, Allergies
Do you have any dietary restrictions?*

YesNo
Please explain your dietary restrictions:
Do you have any activity restrictions?*

YesNo
Please explain your activity restrictions:
Please list any allergies you have (food, medication, other):*
If you do not have any allergies, please write none.

Insurance and Healthcare Providers
Are you covered by medical/hospital insurance?*

YesNo
Please upload a picture of your insurance card (front and back)

Browse Files

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Primary Care Provider
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Dentist
Name:

First NameLast Name
Phone Number:

Area CodePhone Number

Agreements and Waivers

If you are under 18 years old, a parent/guardian must also sign the agreements and waivers.
Parent/Guardian Agreement: I give full permission for the applicant to attend Youth Camp at Camp Wilmot and to participate in all phases of the program. I understand that every effort will be made to protect and safeguard all participants. Therefore, I agree not to hold the Presbytery of Northern New England, Camp Wilmot, its Board of Directors or its agents liable for any illness or for any mishap from any cause whatsoever which may be sustained. I understand that a Medical Information Form, signed by a physician, must be turned in prior to the start of camp, and the applicant must have had a physical within one year of the start of camp. I authorize Camp Wilmot Directors to handle all matters of discipline. I understand that any staff member disregarding camp rules will be sent home. I understand that any staff member who willfully destroys or defaces any property will be responsible and charged accordingly.

Yes
Release of Liability: In consideration for the applicant being permitted to participate at Camp Wilmot, in related events and activities, the undersigned acknowledges and agrees that as the natural parent and/or as the legally authorized guardian, do hereby for myself, my spouse, the applicant, and on behalf of my/our heirs, personal representatives, and assigns, agree not to sue and hereby release, waive, discharge, hold harmless and indemnify and forever defend Camp Wilmot from any and all liability, losses, claims, actions, suits, procedures, demands, rights, and causes of action of whatever nature, in law and equity, for any and all known or unknown, foreseen or unforeseen, bodily or personal injuries, death and permanent injury, illnesses, damage to property, or other losses, and any consequences thereof, including expenses, costs, and attorney’s fees, as may be sustained by the applicant or me arising out of or in any way associated with the applicant’s participation at Camp Wilmot, or travel incident thereto, whether by negligence or not to the fullest extent permitted by law. The risk of serious injury to the applicant from these camp activities does exist including the potential for permanent disability and death. I understand and fully acknowledge that the applicant’s participation in these activities is solely at our own risk and I assume full responsibility. I hereby further declare that the applicant has had a physical examination within the past year and is physically able to participate in all camp activities. Moreover, I hereby understand and affirm that the camp only provides for excess medical insurance and any charges including deductibles related to the medical care provided to the applicant will be the responsibility of my primary insurance carrier or me. I HAVE CAREFULLY REVIEWED AND VOLUNTARILY AGREE TO THE TERMS OF THIS CAMP WAIVER AND RELEASE OF LIABILITY AGREEMENT.

Yes
Media Release: I authorize Camp Wilmot to take and use photographs, slides, and videotapes of myself or the applicant without compensation for the purpose of promotion and/or website use.

YesNo
Off-Site Waiver: I give my permission to Camp Wilmot to take the applicant on short walks outside of camp property, not to exceed a distance of 2.5 miles from camp. I further absolve the camp of all responsibility for any accident or injury that may occur due to causes other than gross negligence on the part of Camp Wilmot or its staff. Should any difficulties arise, the situation will be dealt with according to the policies of Camp Wilmot.

Yes
Off-Site Transportation Waiver: I give my permission to Camp Wilmot and the Director Team to transport the applicant in a Camp designated vehicle off-site. I understand that the applicant is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, the applicant may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses

Yes
Authorization: This health history is correct and accurately reflects the health status of the individual to whom it pertains. The person described has permission to participate in all camp activities except as noted above and/or by an examining licensed medical professional. I give permission to the licensed medical professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the individual for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the individual. I understand the information on this form will be shared on a 'need to know' basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of the described individual's health record from providers who treat them and these providers may talk with the program's staff about the described individual's health status.
Parent/Guardian Signature

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Applicant Signature

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Camp Wilmot 2024 Staff Registration Form

Church Information

Emergency Contact Information

Contact #1

Contact #2

Diet, Activity, Allergies

Medications and Health History

Immunizations

Insurance and Healthcare Providers

Primary Care Provider

Dentist

Agreements and Waivers