M3 Camper 2024 (Student 18+)
Camper Info - Waiver Form - Medical Info for attendees of M3 CAMP hosted by the Southern Baptist of Texas Convention and associated Camps: (Highland Lakes Camp and Conference Center in Spicewood, Tx; Mt Lebanon Camp, in Cedar Hills, Tx; OR Glorieta Adventure Camp, Glorieta, NM)
CHURCH
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What church is bringing your camper(s) to M3 Camp?
CHURCH NAME
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Please Select
Breakout Speaker/Guest
Arise Community Church, Silver City
Bar Nun Ministries, Omaha
Believers Fellowship, Magnolia
Bellview Baptist, Midland
Benchmark Bible Church, Corinth
Bethel Baptist Church of Texas, Lewisville
Broadview Baptist Church, Abilene
Calvary Baptist Church, San Marcos
Caney Creek Baptist Church, Malakoff
Celebration Church, Montrose, CO
Central Baptist Church, Blooming Grove
Central Baptist Church, Livingston
Cherokee Baptist Church
CityView Church, Pearland
Coastal Oaks Church, Rockport
College Avenue Baptist, Levelland
College Avenue Baptist Church, McGregor
Concord Baptist Church, Waco
Cornerstone Bible Church, Decatur
Cross Church, North Richland Hills
Cross City Church, Euless
Cross Fellowship Church, Aubrey
Crosspoint Church, McKinney
Crossridge Church, Little Elm
Crosswinds Community Church
Crosswinds community church, Hobbs
East Paris Baptist Church, Paris
Emet Church, Humble
Emmanuel Baptist Church, New Caney
Emmanuel Baptist Church, Terrell
Fairview Baptist Church, Sherman
Faith Family Baptist Church, Kingwood
FBC Archer City
FBC Benbrook
FBC Childress
FBC Hamlin
FBC Jayton
FBC Kemp
FBC Savoy
FBC Sudan
FBC Taylor
Fellowship of the Parks, Fort Worth
Field Street Baptist Church, Cleburne
First Baptist, Buna
First Baptist, Malakoff
First Baptist, Whitewright
First Baptist, Belton
First Baptist Church, Tomball
First Baptist Church, Farmersville
First Baptist Church, Farwell
First Baptist Church, Friona
First Baptist Church, Iowa Park
First Baptist Church, Kerens
First Baptist Church, Rogers
First Baptist Church, Corinth
First Baptist Church, Groesbeck
First Baptist Church of Hawkins
First Baptist Church of Jayton
First Baptist Church of Lavon
First Baptist Church of Lillian
First Baptist Church Tahoka
First Baptist Edinburg
First Baptist Fredericksburg
First Baptist Silsbee
First Baptist Whitewright, Whitewright
FiveStone Community Church, Garland
Flower Mound First Baptist, Flower Mound
Fredonia Hill Baptist Church, Nacogdoches
Freedom Fellowship, Roanoke
Freedom Hill Church, San Antonio
Gateway Baptist Church, Tuscola
Gateway Community Church, Wylie
Genuine Faith Community Church, Greenville
Grace Baptist Grandview
Grace Community, Corsicana
Gracepointe, Denton
Great Hills Baptist Church, Austin
Harvey Baptist Church, Stephenville
Heights Baptist Church, Alvin
Hillcrest Baptist Church, Bryan
Hope Church, Montgomery
Hope Church, Kyle
Iglesia Agape, Fort Worth
Island Baptist Church, South Padre Island
Junction First Baptist, Junction
Lakeland Baptist Church, Lewisville
Legacy Hills Church, Celina
Living Water Christain Fellowship, Canyon
Meadowbrook Baptist Church, Rockdale
New Day Church, Pasadena
North Park Baptist, Sherman
Paramount Baptist Church, Amarillo
Point View Baptist Church
Porter First Baptist Church
Redeemer Church, Tomball
Renewed Life Baptist Church, Gladewater
Roby FBC
Second Baptist, Andrews
Southlake Baptist Church
Spring Baptist Church
Spring Creek Baptist Church
Stonegate Church Midlothian
Summer Grove Baptist Church, Shreveport, LA
Talty Baptist Church, Crandall
Tate Springs Baptist Church, Arlington
The church at Quail Creek, Amarillo
The River, Channelview
Trinity Baptist Church, Amarillo
Trinity Baptist Church, Mt. Pleasant
Vantage Point Church, Haslet
Vista Grande Baptist Church, Colorado Springs
Waves of Faith, Fort Worth
Western Hills Baptist, Wichita Falls
Whitharral Baptist Church
What church is bringing your camper(s) to M3 Camp?
Which camp are you attending?
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Mt. Lebanon May 28-June 1
Highland Lakes July 1-5
Highland Lakes July 8-12
Glorieta July 11-15
GROUP LEADER NAME
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First Name
Last Name
GROUP LEADER EMAIL
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Camper - Name
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First Name
Last Name
Camper Profile Picture
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Camper - Biological Sex:
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Male
Female
Camper - Date of Birth
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DD/MM/YYYY
Camper - Grade Completed (as of 2023-2024 school year):
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6th
7th
8th
9th
10th
11th
12th
Camper - Shirt Size:
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S
M
L
XL
XXL
XXXL
Parent/ Guardian - Name
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First Name
Last Name
Parent/ Guardian - Email
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Parent/ Guardian - Contact #
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Please enter a valid phone number.
Parent/ Guardian relation to Camper
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Mother, Father, Guardian, etc
CAMPER SIGNATURE AGREEMENT TO ATTEND, PARTICIPATE, ASSUMPTION OF RISK AND RELEASE OF LIABILITY: I, the parent or legal guardian, of the above mentioned minor, am/are fully informed about and aware that during the above mentioned minor's stay at the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) in connection with an event of the Southern Baptist of Texas Convention (SBTC), certain risks and dangers will occur. These include, but are not limited to, the hazards that raise from being in a wilderness area, the forces of nature and other hazards arising out of the content of this program which include, but are not limited to, volleyball, softball, basketball, archery range, wilderness hiking, swimming, use of water crafts, and a challenge course which has a climbing wall, zip lines, high and low elements, and a team power pole. In consideration of the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) and the SBTC providing and the minor's willingness to engage in these rigors activities and a special environment, I have and do hereby hold the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) and the SBTC their owners, officers, directors, trustees, agents, employees, and/or volunteers, harmless from any and all claims, liabilities, suits, actions, causes, damages, or losses and demands of every kind and nature whatsoever, including with limitation, all costs and attorney fees, which may arise from or in connection with the above mentioned minor's stay or participation in any activities arranged for the above mentioned minor by the attending organization or group leaders, the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM), or SBTC. Injuries may include, but are not limited to emotional injuries, physical injuries, or death. The terms hereby shall serve as a release and assumption of risk for the above mentioned minor, parent(s)/guardian(s), heirs, executors, administrators, and for all family members of the above mentioned minor. CAMPER/MINOR SIGNATURE
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Camper/ Minor Printed Name and Date
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Printed Name
Date of Signature
PARENT/GUARDIAN SIGNATURE - AGREEMENT TO ATTEND, PARTICIPATE, ASSUMPTION OF RISK AND RELEASE OF LIABILITY: I, the parent or legal guardian, of the above mentioned minor/ my child, am/are fully informed about and aware that during the above mentioned minor's stay at the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) in connection with an event of the Southern Baptist of Texas Convention (SBTC), certain risks and dangers will occur. These include, but are not limited to, the hazards that raise from being in a wilderness area, the forces of nature and other hazards arising out of the content of this program which include, but are not limited to, volleyball, softball, basketball, archery range, wilderness hiking, swimming, use of water crafts, and a challenge course which has a climbing wall, zip lines, high and low elements, and a team power pole. In consideration of the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) and the SBTC providing and the minor's willingness to engage in these rigors activities and a special environment, I have and do hereby hold the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) and the SBTC their owners, officers, directors, trustees, agents, employees, and/or volunteers, harmless from any and all claims, liabilities, suits, actions, causes, damages, or losses and demands of every kind and nature whatsoever, including with limitation, all costs and attorney fees, which may arise from or in connection with the above mentioned minor's stay or participation in any activities arranged for the above mentioned minor by the attending organization or group leaders, the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM), or SBTC. Injuries may include, but are not limited to emotional injuries, physical injuries, or death. The terms hereby shall serve as a release and assumption of risk for the above mentioned minor/ my child, parent(s)/guardian(s), heirs, executors, administrators, and for all family members of the above mentioned minor. MEDICAL ADMINISTRATION: I the parent, guardian of the above mentioned minor/ my child, in he case of accident or illness, authorize the nurse of the attending camp of the above mentioned minor (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) or first aid personnel to examine, treat, or administer medications for any illness or injury to the above mentioned minor/ my child as deemed necessary. In the event of an emergency involving the above mentioned minor/ my child and if I, the parent/guardian, cannot be reached by telephone, I authorize such persons to obtain any medical care (including hospitalization, injection, anesthesia, and surgery) from a licensed, certified, or authorized health care provider for the above mentioned minor/ my child as deemed necessary. I accept sole responsibility for the payment or any medical care for the above mentioned minor/my child. I hereby release, indemnify and hold harmless teh attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM), the STBC, their owners, officers, directors, trustees, agents, employees, and/or volunteers from and against any adn all claims liabilities, or damages arising from any act, omission, negligence, or gross negligence of any such health care provider or attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM), or the SBTC, their owners, officers, directors, trustees, agents, employees, or volunteers. PHOTO RELEASE: I, the parent/ guardian of the above mentioned minor/ my child, give permission for the photography and videoing the above mentioned minor/ my child by the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) the SBTC for the sole purpose of digital and printed promotional mediums. RELEASE, WAVIER, INDEMNITY: I expressly agree the release, wavier, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Texas and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and have understood. PARENT/GUARDIAN SIGNATURE
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Parent/Gaurdian Printed Name and Date
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Printed Name
Date of Signature
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CAMPER MEDICAL - Family Physician
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CAMPER MEDICAL - Insurance Co
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CAMPER MEDICAL - Plan or Group #
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CAMPER MEDICAL - Insured ID # or Member #
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CAMPER MEDICAL - Ins. Co. Phone
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CAMPER MEDICAL - List any and all allergies for the camper:
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Allergies: Food, Insect, Medicine, Drug, Plant, Pollen, other
CAMPER MEDICAL - List any and all dietary restrictions:
Allergies: Food, Insect, Medicine, Drug, Plant, Pollen, other
CAMPER MEDICAL - List any recent or major surgeries:
Allergies: Food, Insect, Medicine, Drug, Plant, Pollen, other
CAMPER MEDICAL - Disease, Chronic, or Recurring illness (check all that apply):
Asthma
Bleeding Disorder
Dermatological Condition
Diabetes
Ear Infections
Heart Defects
Seizures
Stomach Conditions
Emotional
CAMPER MEDICAL - Elaborate on any above medical conditions. Please provide any information to assist medical attention (if needed):
Allergies: Food, Insect, Medicine, Drug, Plant, Pollen, other
CAMPER MEDICAL - Approved medications for minor to receive by medical provider:
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Acetaminophen (ie Tylenol)
Antihistamine (ie Benadryl, Claritin)
Antacid tablet (ie Tums)
Ibuprofen (ie Advil)
Antihistamine Cream
Decongestant (ie Sudafed)
Antibacterial ointment
Additional medications (check here AND comment below)
CAMPER MEDICAL - Any additional medications
HEALTH CARE AND CAMP PERMISSION: Highland Lakes Camp and Conference Center AND Mt Lebanon Camp Requirements: Texas State law requires all medications to be placed in the campus Health Care Center. All medications must be brought in the ORIGINAL CONTAINER (prescription and/or over-the-counter) AND PROPERLY LABLED as prescribed by state law. Prescriptions labels must have the camper's name and current dosage. A current Medication Administration Authorization Form MUST accompany all medication(s). Highland Lakes Camp and Conference Center AND Mt Lebanon Camp Medical request that you NOT send over the counter medications such as Tylenol, Ibuprofen, Benadryl, or Antihistamines. Highland Lakes Camp and Conference and Mt Lebanon Camp stock an assortment of over-the-counter medications for the occasional use. PERMISSION: By signing, I, the parent/guardian of the above mentioned minor/ my child, give permission for the first aid techniques and simple health care to be administered as the need arises. I understand in the event of any serious injury or illness on the part of my child/ward, the camp officials, reserve the right to see professional medical attention including but not limited to consultation with a medial director, EMS Transportation, and hospitalization. Furthermore, I give permission for the above mentioned minor/ my child in consultation with the Camp Heath Supervisor and/or medical director's standing orders to be given the above approved medications. Campers attending GLORIETA ADVENTURE CAMP follow New Mexico State laws. As such, the attending church may provide their own listened medical provider under the direction and care of the attending church. If a linseed medical provider is not provided then the SBTC will provide a listened medical provider to administer approved medications. If a church chooses to use the provided medical provider then, I, the parent/guardian, affirm the same processes as mentioned for the Highland Lakes Camp and Conference Center and Mt Lebanon Camp. ATTEST ACCURATE MEDICAL INFORMATION: By signing, I, the parent/ guardian of the above mentioned minor/ my child, hereby attest all information listed above as MINOR MEDICAL is complete and accurate to the best of my knowledge, that the above mentioned minor/my child is in acceptable health, physical ability, and emotionally ready to fully participate in all camp actives. In addition, I grant my permission, as the parent/guardian of the minor mentioned above/my child, to participate in all activities associated with the enrolled event with exceptions of those that are noted. Lastly, I, the parent/ guardian, give permission for Highland Lakes Camp and Conference Center, Mt Lebanon Camp, Glorieta Adventure Camp management, medical staff, and/or group director to provide medical treatment that may be deemed necessary to insure the well-being of the above mentioned minor/my child. I do hereby releaser and forever discharge all from any and all claims, demands, actions, or cause of action arising out of damage or injury while participating the attending camps (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) and SBTC sponsored activities. PARENT/GUARDIAN SIGNATURE
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Parent/Gaurdian Printed Name and Date
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Printed Name
Date of Signature
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MEDICATION ADMINISTRATION AUTHORIZATION: My child/ the above mentioned camper:
is bringing medication.
is NOT bringing medication.
Camper: Name
First Name
Last Name
Camper: DOB
Camper: Biological Gender:
Male
Female
Camper: Age
Church and Group Leader
Church Name
Group Leader
PARENT/ GUARDIAN: As the parent/ guardian of the above mentioned camper, by signing, I give permission for the attending camp (Highland Lakes Camp and Conference Center in Spicewood, Tx; OR Mt Lebanon Camp in Cedar Hill Texas; OR Glorieta Adventure Camp, Glorieta NM) to administer as prescribed by law the following listed medications to my child (listed above as an attending camper). MEDICATION GUIDELINES: Furthermore, by signing, I, the parent/guardian of the above mentioned camper/ my child, understand and agree to the following medication guidelines. In accordance with Texas Department of Health regulations: ALL Medications brought with the attending camper must be: 1) Placed in a secure location not accessible to campers; 2) Prescribed for teh camper (not a sibling or parent); 3) in the original container with all labels intact; and 4) correct current dosage. Dosage of non-prescription medication may not exceed product recommendation without doctor's written orders. Attending camps ask all parents to not send over-the-counter medication (Tylenol, ibuprofen, Benadryl ,etc). These types of medications are provided by the attending camp. MEDICATIONS: Lastly, by signing, I, the parent/guardian of the above mentioned camper, verify the medications and dosages are correct as prescribed by the prescribing doctor.
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Parent/ Guardian Printed Name and Date Signed
Printed Name
Date Signed
Name of Medication #1:
Purpose of Medication #1:
Form of Medication #1:
Tablet
Pill
Capsule
Liquid
Inhalation
Other (specify below)
Form of Mediation #1 "OTHER"
Medication #1 Dosage:
Medication #1 Frequency:
Medication #1 Remarks or Special Instructions:
Name of Medication #2:
Purpose of Medication #2:
Form of Medication #2:
Tablet
Pill
Capsule
Liquid
Inhalation
Other (specify below)
Form of Mediation #2 "OTHER"
Medication #2 Dosage:
Medication #2 Frequency:
Medication #2 Remarks or Special Instructions:
Name of Medication #3:
Purpose of Medication #3:
Form of Medication #3:
Tablet
Pill
Capsule
Liquid
Inhalation
Other (specify below)
Form of Mediation #3 "OTHER"
Medication #3 Dosage:
Medication #3 Frequency:
Medication #3 Remarks or Special Instructions:
Name of Medication #4:
Purpose of Medication #4:
Form of Medication #4:
Tablet
Pill
Capsule
Liquid
Inhalation
Other (specify below)
Form of Mediation #4 "OTHER"
Medication #4 Dosage:
Medication #4 Frequency:
Medication #4 Remarks or Special Instructions:
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Ministry Safe or Equivalent Child Protection Certification
I have a child protection certification on file with my attending church.
I have NOT completed a child protection certification.
I am unsure if I have a child protection certification on file with my local church.
Background Check
I have a valid background church on file with my attending church.
I do NOT have a background check on file with my attending church.
I am unsure if I have a background check on file with my attending church.
Submit
Submit
Should be Empty: