APEX 2025 - Adult Leaders

What church are you attending with?*
Adult Leader Information
Name*

First NameLast Name
Age as of 6/24/25*
Gender*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
T-shirt Size*

Can you take the following medications if necessary?*

	Yes	No
Tylenol
Ibuprofen
Neosporin Ointment
Benadryl
Cortisone Cream
Equate Anti-diarrheal
Visine

List any medications you cannot take:*
List any known allergies:*
Are you covered by health insurance?*

YesNo
Insurance Company Name*
Insurance Phone Number*
Please enter a valid phone number.
Primary Insured*

First NameLast Name
Policy Number*
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.

Please check all immunizations you hav received:*

	Check All That Apply
Diphtheria/Tetanus/Pertussis (DTaP/DTP/DT/Td/Tdap)
Polio
Measles, Mumps & Rubella (MMR)
Hepatitis B
Varicella (Chicken Pox)
Meningococcal (Meningitis)
Hepatitis A
Do Not Immunize

READ CAREFULLY AND SIGN: I hereby request that my child (or I being 21 years or age or older) be accepted to attend Camp Ta-Ku- La. I understand and am aware that my child (or I) will be participating daily in many physical activities and that the potential for accidents and or exposure to pathogens does exist. I hereby give my permission for my child (or myself) to ride in camp buses and vehicles. Furthermore, I authorize the camp to furnish food, lodging and transportation to my child (or myself.) As further consideration for the acceptance of my child (or myself) to attend Camp Ta-Ku-La, I, individually, or on behalf of my child, hereby release, discharge, indemnify and hold Camp Ta-Ku-La and the sponsoring church or organization and respective directors, officers, employees, agents and representatives (the Released Parties) from any and all liability and any and all claims or demands for loss or damage on account of injury, illness or death to a person or property, and any and all costs and expenses, including without limitation attorney’s fees, whether caused in whole or in part by the negligence of the Released Parties or any of them, as a direct or indirect result of my child’s (or my) attendance at Camp Ta-Ku-La, and I, individually, and on behalf of my child (or myself) hereby waive any and all claims and causes of action against the Released Parties or any of them, resulting directly or indirectly from my child’s (or my) attendance at Camp Ta-Ku-La.

PARENTS AUTHORIZATION TO PROVIDE NECESSARY TREATMENT: I hereby give permission to the medical personnel selected by the camp director and/or staff to order X-rays, routine tests, treatment, to release any and all records necessary for insurance purposes, and to provide or arrange related transportation for me or my child. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp director and/or staff to secure and administer treatment including emergency treatment, surgery or hospitalization, for the person named above. I assume the responsibility of all medical bills and ancillary incurred expenses. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation costs.

Activities: I give my child permission to participate in all activities (zip-line, climbing tower, human foosball, cage dodge ball, and gun range)

Camp Ta-Ku-La has my permission to use photographs and videos of my child named above taken during camp for promotional purposes. No first and last names will be published without permission.

I have read and understand the foregoing terms and conditions, including without limitations the release provision, and by my signature knowingly agree to each and every term and condition as stated above.
Signature*

Clear
Printed Name*

First NameLast Name
Date*

MonthDayYear
Date

Payment Calculation

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Thank you for participating in APEX 2025.

We are looking forward to an amazing week together!

Please click "Submit" below to finalize your registration.
Should be Empty:

	True	False
Sexual abuse can occur without touching.
Abuse and neglect may negatively affect a child's emotional and social development.
Exposing a child to pornographic material is not considered abusive.
Not only forced activity, but persuasion can be considered abusive.
Victims of child abuse often suffer from fear, guilt, and anger.
Child is defined as anyone, unmarried under the age of 16.
Sexual abuse may negatively affect a child for their entire lives.

Adult Leader Information