Resilient Warriors Club Registration

Resilient Warriors Club Registration

Our mission with camp is to Restore, Empower & Strengthen Alaska's At Risk Youth & Families so All Children in Alaska Know They Are Loved & Cared For. Resilient Warriors meet on the 3rd Saturday of each month - Location TBD.
Is your youth currently a client of REACH907?*

YesNo
Are you planning to register more than one child?*

YesNo
If yes, how many children will you be registering?

Resilient Warriors Club
Which months are you hoping to attend? (Select all that apply)*

SeptemberOctoberNovemberDecemberFebruaryMarchAprilMay

Youth History
Are you aware of Adverse Childhood Experiences (ACES)? If so, what are some of the ACES of your child? (This is how we qualify youth for the proper trauma-informed camp to meet their needs).*
Please list and describe behaviors most commonly displayed by your youth.*
Does your youth have any mental health diagnoses?*

YesNo
If yes, please list youth diagnoses.
To the best of your knowledge, what is the trauma history of your youth? What is their story?*

Parent/Guardian Information
Primary Caregiver*

First NameLast Name
Primary Caregiver Email*
example@example.com
Primary Caregiver Cell Number*
Please enter a valid phone number.
Secondary Caregiver (if applicable)

First NameLast Name
Secondary Caregiver Email
example@example.com
Secondary Caregiver Cell Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Information
Youth Name*

First NameLast Name
Youth T-Shirt Size*
Youth Two*

First NameLast Name
Youth Two T-Shirt Size*
Youth Three*

First NameLast Name
Youth Three T-Shirt Size*
Youth Four*

First NameLast Name
Youth Four T-Shirt Size*
Youth Five*

First NameLast Name
Youth Five T-Shirt Size*
Youth Six Name*

First NameLast Name
Youth Six T-Shirt Size*
Caregiver Name*

First NameLast Name
Caregiver Email*
example@example.com
Caregiver Cell Number*
Please enter a valid phone number.

Requirements/Expectations
I understand there is a $50 registration fee per youth / $100 registration fee per teen.*

I UnderstandI Do NOT UnderstandThis fee presents a hardship for my family. (Please contact us so we can work with you.)
NOTE: When applicable, you will recieve an invoice for camp fees.

Make checks out to REACH 907, mail to:

PO Box 876646, Wasilla, AK 99687

For credit cards, call us at 907-745-6200
I give permission for Staff to take pictures of my youth for their photo album (faces will be obscured if used in other than their album).*

I give permissionI do NOT give permissionI would like further information
I give permission for Staff to take pictures of my youth for possible promotional purposes (faces will be obscured)*

I give permissionI do NOT give permission
Communications

I give permission to REACH907 to contact me via text and/or email with information and reminders regarding required documents, payments, event reminders, and/or updates, etc.

Informed Consent and Acknowledgments
Informed Consent and Acknowledgement

I hereby give my approval for my youth’s participation in any and all activities during the selected camp. In exchange for the acceptance of said youth’s candidacy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless REACH 907 and TeenReach Adventure Camp (TRAC), and all its respective officers, agents, and representatives from any and all liability for injuries to said youth arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said youth, I hereby waive all claims against REACH 907 and TRAC, including all affiliates, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all camp activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Informed Consent and Acknowledgment*

I understand and consentI do not understand nor consent
Medical Release and Authorization

As Parent and/or Guardian of the named child(ren), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child(ren), in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life(lives), physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to REACH 907 and its affiliates including Directors and Staff to provide the needed emergency treatment prior to the youth’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child(ren), in my absence.

During camp, prescription medication will be administered to youth as directed by a physician. REACH 907 will do everything in its power to prevent incorrect medicine from being given. However, the local REACH 907 and TRAC, are not liable for incorrect medicine provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medication, bottles, and dosages at the time of registration. This is not the time to give medication vacations to your youth.
CONFIRMATION

BY ACKNOWLEDGING AND SIGNING BELOW, I AM COMMITTING TO A REACH 907 PROGRAM FOR A CHILD IN MY CARE.

I ACKNOWLEDGE THAT REACH 907 IS A FAITH-BASED ORGANIZATION OPERATING A FAITH-BASED CAMP PROGRAM.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AND BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Caregiver or Legal Guardian E-Signature*
Should be Empty:

Resilient Warriors Club Registration

Resilient Warriors Club

Warrior Registration Information

Youth History

Additional Youth Information

Parent/Guardian Information

Client Information

Emergency Information

Requirements/Expectations

Informed Consent and Acknowledgments