2025 NEOLA/MUP at JO-OTA Camp App

2025 Mid-America Disciples & Missouri Union Presbytery Summer Ministries Registration and Health History NorthWest Camps at Crowder State Park

Complete a separate registration form for each event - return form to your Disciples congregation or to CCMA Registrar (address on next page)

Please Select a camp week (all grade levels are those JUST COMPLETED):

CYF (9th 12th Grade July 7-12 $385)

Elem/Junior (2nd-5th Grades July 14-18 **Elem Camp Leaves late afternoon of 16th** Elem $195 Jr 345***)

Chi-Rho(6th-7th Grades** July 28-Aug 2 $375) **email Camp Cordinator Zane Whorton at zanew78@gmail with any questions or concerns

Camper Name (Last,First)

Date of Birth

Date

Gender (There is a place on health for to mark for more info if needed)

Grade Just Finished

Year of HS Graduation (last 2 numbers. "24" for example for 2024

T shirt Size(YS, YM, YL,S,M,L,XL, 2x, etc)

List any person who is not to pick up your child and list reason:

Does Camper Swim (Y or N)* Writes on bottom of health form is more room is needed

Try It, Elementary, Junior Camper cabin mate request (1 name only/must be mutual)

Address

Participant Address

Street Address Line 2

City/State/Zip

Home Phone Number

Please enter a valid phone number.

Participant Phone Number

Please enter a valid phone number.

Local Congregation & City

Pastor's or Youth Pastor's Name

Pastor's or Youth Pastor's Email Address

example@example.com

Parent/Guardian's Name

E mail

example@example.com

Complete Address (if different from Participant)

Cell Phone Number

Please enter a valid phone number.

Other Phone Number

Please enter a valid phone number.

Secondary Parent/Guardian's Name

E mail

example@example.com

Complete Address (if different from Participant)

Cell Phone Number

Please enter a valid phone number.

Other Phone Number

Please enter a valid phone number.

If Parents/Guardians are unavailable in emergency, notify (name)

Relationship to Participant

Primary Phone Number

Please enter a valid phone number.

Other Phone Number

Please enter a valid phone number.

Releases and Authorizations: please check to be sure all signatures (3) and initials (3) are completed below. This Registration & Health History is correct and complete as far as I know. The person herein named as "participant" has permission to engage in all activities except as noted. I hereby give permission to event leaders to provide, seek, and consent to routine health or dental care, administration of prescribed medication, and emergency treatment for me/my child, as may be deemed necessary, including but not limited to x-rays, routine tests, and treatment, and/or hospitalization. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that event leaders be treated as acting in loco parentis if the person herein named is a minor. Further it is my intention that the appropriate event representatives be treated as "personal representatives" for the purposes of disclosing protected health information pursuant to the Health Insurance Portability and Accountability act of 1996. I hereby agree (pursuant to 45CFR$164.510(b to the disclosure to these representatives of the protected health information of the person herein described, as necessary; (1) to provide relevant information to event representatives related to the person's ability to participate in activities; and (2) in the case of minors, relevant information to event representatives to keep me informed of my child's health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by event leaders to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp.

Please initial Medication, Transportation and Photography Releases:

1. We/I authorize staff to administer over-the-counter medication to my child for minor pain, headache, upset stomach, sore throat, cold symptoms, or allergy. Intial Below or write "NO"*

2. We/I give permission for our/my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Mid-America Disciples (DOC)and Missouri Union Presbytery SummerMinistry. Initial Below or write "NO"*

3. We/I give permission for our/my child to be photographed, video or audio taped and understand that these photos, videos, or recordings may be used in Mid-America of the Christian church (DOC) and Missouri Union Presbytery newsletters, promotion or other print, digital or internet publications. Initial Below or write "NO"*

Signature of Custodial Parent/Guardian (use finger or mouse to sign)*

Printed Name*

Date

Participant Covenant: I covenant with my Creator, event staff, and other participants to do my best to: Expect the best of others, and give my best in our activities together. Respect each person's dignity, affirming that each one is created VERY GOOD, in the image of God. Participate fully in activities and attend the entire event. Be a good steward of creation, appreciating and caring for the environment. Abide by rules, policies, and expectations of the camp/event. Grow in my relationship with Jesus Christ, through prayer, Bible study, Create a community of hospitality and worship and fellowship.Expect to make new friends, be a friend to others, and have fun. inclusion that honors the unique contributions of each person.Respect event property and personal belongs of participants and staff.

Participant's Signature (use mouse or finger to sign)*

Date

Health History for (Participant name

Date of Last Physical Exam

Date

Date of Last Tetanus

Date

Insurance Information:

Is the participant covered by medical /hospital insurance (Yes or No)*

If so, list Name On Card or write "none"*

Carrier or plan name or write "none" *

Policy and or Group #*

Physician

Phone Number

Please enter a valid phone number.

Dentist/Orthodontist

Phone Number

Please enter a valid phone number.

ALLERGIES List all known Include medicines, food, insect stings or bites, hay fever, asthma, animal, etc. If you need more room please email zanew78@gmail.com

Describe reaction and management of reaction. If you need more room please email zanew78@gmail.com

Diet, Nutrition, Please sect one.*

This Participant Eats a Regular DiestThis Particiapnt Eats a Regular Vegetarian DietThis Particiapnt has Special Food Needs

If needed please explain food needs. If you need more room please email zanew78@gmail.com

MEDICATIONS BEING TAKEN Please list all medication (including over-the-counter or non-prescription drugs) Bring enough medication to last entire camp/event. All medication must be in the original package that identifies the patient, prescribing physician (if prescription drug), name of the medicine, dosage and frequency of administration. If more space is needed, please attach an additional sheet. Medication & Dosage.When given & reason for taking medication

Medication & Dosage. If you need more room please email zanew78@gmail.com

When given & reason for taking medication. If you need more room please email zanew78@gmail.com

Camper Height

Camper Weight

General Health: Check Yes or No for each statement:

Has or does the participant:*

	Yes	No
1.Had a recent injury, illness or infectious disease?
2.Have a chronic or recurring illness/condition?
3.Ever Been Hospiitalized?
4.Ever Had Surgery?
5.Ever had a head injury?
6. Had fainting or dizziness?
7.Ever Had Seizures of convulsions?
8.Ever passed out/had chest pain during or after exercise?
9.Have Diabetes?
10 Have asthma/wheezing/shortness of breath?
11. Ever had back/joint problems?
12. Ever had skin problems(e.g. itching, rash acne)?
13. Had monoucleosis ("mono") in the past 12 month?
14 Had problems with diarrhea or constipation?
15 Had problems falling asleep, sleepwalking, etc.
16 Have a problem with periods/menstartion?
17 Have a history of bedwetting?
18 Wear glasses, contacts or protective eyeweard?
19 Traveled outside the country in the last 9 months?

Please explain if answered "Yes" to any above. Include the question number. If participant has travled out of the country, please list all contries traveled to. If you need more room please email zanew78@gmail.com

Mental. Emotonal and Social Health: Please write yes or no and use the space below to further explain in needed

1. Ever been treated for attentiondeficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?

2. Ever been treated for emotional orbehavioral difficulties or an eating disorder?

3. During Past 12 months, seen a professional to address mental/emtional health concerns

4.Had a significant life event that continuesto affect the camper's life?(history of abuse, death of a loved one, family change adoption, foster care, new sibling,survived adisaster, otherntal/emtional health concerns

Please explain if answered "yes" to any above. If you need more room please email zanew78@gmail.com

What have we forgotten to ask? Use this space to provide any additional information about the participant's health or behavior that you think important or that may affect his/her ability to participate fully in the camp/event.