2018 2000 Strong Camp Registration and Health Form

2000 Strong Adventure Camp

Registration and Health Form

Camper Informantion

Please fill out a seperate form for each family member.

Full Name*

First NameLast Name

Gender*

MaleFemale

Birth Date*

MonthDayYear

Grade Completed*

Age must be 8-18*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Primary Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Email

Cabin Mate Request

Parent/Guardian with legal custody to be contacted in case of illness of injury

Name*

First NameLast Name

Preferred Phone Number*

Area CodePhone Number

Medical Information

Does the camper have any known allergies, chronic illness or other medical conditions? If yes, please describe.

Does Camper have any known allergies to the following

Please list all medications (including over-the-counter or non-prescription drugs) taken routinely.

All medicine must be in its original container identifying the prescribing physician (if a presciption), medicine name, dosage and frequency of administration; otherwise, we will be unable to dispense the medication to your child. Please bring enough medicine to last the entire camp. All medicines must be turned over to the Camp Health Officer during check-in.

Does the camper have any dietary restrictions? If yes, please provide instructions.

General Health History (please check all the apply)

Has/Does the camper

Had asthma/wheezing/shortness of breath?Have diabetes?Had/Have seizures?Had fainting or dizziness spells?Have problems with falling asleep/sleepwalking?Have a food allergy / carry and epi pen?

Please explain any conditions checked above, or list any additional medical issues

Consents, Releases and Waivers

Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, 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, 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 for the named camper. 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 2000 Strong for Christ and the YMCA to provide the needed emergency treatment prior to the child’s admission to the medical facility.

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

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, in my absence.

Camper Activity Consent

I hereby consent to the above named camper participating in all activities offered by the 2000 Strong Adventure Camp including, but not limited to: camping, boating, swimming, hiking, rock wall climbing, riding the zip line, archery, climbing tower, bb target practice, and sporting events. I have specified below any items from the preceding list for which I DO NOT give consent for the above names camper to participate. I also agree that the above named camper has the necessary skills to participate in the approved activities.

Release and Waiver of Liability and Indemnity Agreement

Whereas the undersigned parent, legal guardian, next of kin, on behalf of himself or herself, his or her personal representatives, heirs, and next of kin, camper, child (herein referred to as "Applicant") or participant acknowledges that even though every effort is made to provide a safe accident-free environment, incidents may occur. In consideration for the camper listed above being accepted by the 2000 Strong Youth for Christ Staff for participation in this camp, I (Applicant) being 21 years of age or older, do for myself, ourselves, Applicant, (and for and on behalf of my child-participant, if said child is not 21 years of age or older) hereby release, forever discharge and agree to hold harmless the aforementioned 2000 Strong Youth for Christ Staff and the Directors, Officers, Volunteers, Servants, and Agents (collectivlely the "Released Parties") Applicant hereby releases, waives and covenants not to sue for, and Applicant shall indemnify, defend and hold harmless 2000 Strong Youth for Christ and Released Parties thereof from and against any economic or non-economic losses, any and all liability, damages, suits, actions, claims and attorney's fees, costs, expenses, or demands of every kind and nature whatsoever, whether for bodily injury, porperty damage, death, or loss otherwise. Whether caused in whole or in part by the negligence, gross negligence or strict liablity of the released parties or otherwise to the fullest extent permitted by law arising from or alleged to have arisin from Applicant's presence, observation, use or participation at or in the 2000 Strong Adventure Camp , and or the presence, observation, use or particitpation of any family member, dependent or guest, including any minors, accompanying applicant at or in the camp. Applicant voluntarily agreess to indemnify, hold harmless, assume full responsibility for and defend the Released Parties from any risk of bodily injury, death, or property damage while Applicant, Applicant's Family Member , Dependent, or Guest including any Minor's accompanying Applicant are present in, observing, using or participating in the camp or arising out of or in any way connected to Applicants, Applicants Family Member, Dependent, or Guest, including claims or demands for personal injury, sickness or death as well as property damage and expenses of any nature whatsoever whether caused in whole or in part by the negligence, gross negligence or strict liability of the Released Parties or otherwise to the fullest extent permitted by law which may be incurred by the undersigned, Applicant, the child-participant that occur while said Child, Applicant is participating in the above described camp. Applicant assumes full responsibility for any items lost or stolen while Applicant is present in, observing, using or participating in the 2000 Strong for Christ Adventure Camp. Applicant also states that Applicant is not under the influence of any chemical substance, including but not limited to, medications, illegal drugs, and/or alcohol, at the time of execution of this Release and Waiver of Liability and Indemnity agreement, and will not be under the infuence of any chemical substance, including but not limited to medications, illegal drugs, and/or alcohol, during the ovservation, use,or participation in or at the 2000 Strong Adventure Camp. In addition, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further agrees to hold harmless and indemnify said organization, its directors, employees and agents for any liability sustained by said organization as the result of the neglegent, willful or intentional acts of said participant, including expenses incurred attendant thereto. Furthermore, in consideration of any child under the age of eight years old must be accompanied by a parent or legal guardian at any and all times including, but not limited to, sleeping in the same cabin as the parent or legal guardian while at 2000 Strong Adventure Camp. Applicant further expressly agrees that this Release and Waiver of Liability and Indemnity Agreement cannot be altered in any way, and is intended to be as broad and inclusive as permitted by Texas Law, and that if any portion of the Release and Waiver of Liability and Indemnity Agreement is held invalid, Applicant agrees that the balance shall, notwithstading, continue in full legal force and effect. Applicant fully understands that Applicant's entrance, observance, use, or participaton of, on, in the 2000 Strong Adventure Camp is entirely voluntary, Applicant has read and understood this Release and Waiver of Liability and Indemnity Agreement, has voluntarily signed this Release and Waiver of Liability and Indemnity Agreement, and argees that no oral representation, statement, or inducement apart from this written agreement have been made to Applicant.

Transportation Waiver:

Each child/passenger and his/her parent/guardian agrees to assume all risk of and responsibility for personal injury or damage to or loss of property of, the child/passenger arising from, based upon or relating to the child/passengers participation in the bus trip to and from camp. Each child/passenger and his/her parent/ guardian understands and agrees that, in the event of any injury to the child/passenger 2000 Strong for Christ will not be held responsible for any decision relating to medical treatment for the child/passenger or for such treatment itself.

I hereby waive, release, and discharge 2000 Strong for Christ its Board members, officers, and volunteers from any claim, demand, or cause of action arising out of the transportation herein provided and agree to indemnify and save harmless 2000 Strong for Christ its Board Members, officers and volunteers from all claims for loss, damage, or injury sustained by child/passenger, designee.

Camper's Promise

To help make the camp a great experience for everyone, I will abide by the rules and expectations of the camp. I will live by the highest Christian standards or I will be sent home at the expense of my parent (s)/guardian. I will be on time to all activities and ready to participate. I will be courteous, kind and respectful of others and their possessions. I will be respectful to instructors, camp staff and YMCA staff. I will refrain from abusive or derogatory language.

I will not bring tobacco, alcohol, drugs, knives, fire arms, fireworks, matches or cigarette lighters to camp.

I will not leave the campgrounds for any reason.

I WILL NOT BRING NON-PRESCRIPTION MEDICATION TO CAMP AND ALL PRESCRIPTION MEDICINE BROUGHT TO CAMP WILL BE IN THE ORIGINAL CONTAINER CONTAINING MY NAME. (ALL MEDICINE MUST BE TURNED OVER TO THE NURSE.)

I will live by the Golden Rule: Do unto others as I would have them do unto me.

(Failure to meet this policy will result in the camper being sent home at the expense of parent(s)/guardian.)

Photo Release

In consideration of the right of the camper listed above to participate in this camp, I hereby give consent and authorize the taking of photographs or videotape in which my child may appear. I herby waive all rights of privacy in and to any said pictures or tapes.

Please check to acknowledge that you have read and agree to the above consents, releases and waivers. By checking this box you are providing an electronic signature. An electronic signature will be equally as binding as an original manual paper signature.*

I Agree

Signature

Payment Choice 1 - Use payment choice 1 options below if you are paying by credit card at this time, after checking the desired fields below and click submit at the bottom of the form you will be taken to paypal to complete payment.

Payment Choice 2 - Use payment Choice 2 options below if you do not wish to pay now or wish to pay by check please fill out the fields in Payment Choice 2 and click the submit button at the bottom of form.

Bus transportation will be provided to and from Camp.

Bus Pickup and Dropoff is at Church of Jesus Christ

2101 Rosemead PKWY Carrollton, TX 75007.

Campers will Depart to camp on June 11, 2025. Please plan to arrive at 12:00 noon to register and board bus. The bus will leave promply at 1:00.

Please provide your child with a sack lunch to enjoy on the ride to camp.

Campers will return to 2101 Rosemead PKWY Carrollton, Tx on Sunday June 15th at 2:30 to be picked up by parents.

My Child will take bus to and from camp.

Use a credit or debit card.

Adventure Camp Fee$295.00

Tshirt$20.00

Camp tshirt with year and theme.

QuantitySize

Horse Back Ride$20.00

Horse back riding will be provided for an additional fee.

Total $0.00

I will Pay at camp registration. Click on the yes and click submit, You will automatically be taken to paypal page. If you are not paying just exit paypal page and you will automatically be registered.

Yes