SIMC June 9-13 Elementary Camp

Southwest Indian Ministries Camps

World Gospel Mission

14202 N 73rd Ave., Peoria, AZ 85381

Age 9 to 11

June 9-13, 2025

*Please read the entire form carefully. Sign and date the four separate sections. Thank you!

Campers First & Last Name*

Male M or Female F*

Have you attended camp before?

Adult T-shirt Size @ additional $10

T-shirt color? All colors may not be available at the time of camp.

Current Age*

Date of Birth*

Date

Text number*

Email

example@example.com

Mailing Address: *

City*

State*

Zip*

Parent/Guardian's Name(s)*

Name of church you attend

Pastor's Name

Name of friend you're coming with or bringing

Names of all people who have permission to pick your child up from camp*

As the Parent/Guardian, I give permission for my camper to take part in all activities of the camp including but not limited to recreation, field trips, swimming and classroom instruction.

ParentGuardian Signature*

Date*

Date

As the Parent/Guardian, I give my consent to use my child's photograph, likeness or image, whether in still frame, voice or video format by World Gospel Mission/American Indian Field/SIMC in publications, promotional brochures, video presentations, on the world wide web and in display formats.

I understand I am giving this permission with no financial compensation to me in return for the use of my child's photograph, likeness or image, and release World Gospel Mission/American Indian Field/SIMC from any legal liability for the use of said photograph, likeness or image. I hereby give my permission to use my child's photograph, likeness and image of my own free will.

ParentGuardian Signature

Date

Where will you be taking your camper?*

I will be dropping off and picking up my child at the Christian Community Center (formerly known as the Southwest Indian Ministries Center) 14202 N 73rd Ave., Peoria, AZ 185381I will be dropping off and picking up my child at Camp Pinerock (1400 Pine Dr., Prescott, AZ 86303)

I give permission for first aid treatment to be given to my child if deemed advisable by the SIMC staff.

In the event of a medical emergency and I cannot be reached, I hereby give permission to the Lead Staff at SIMC to consent to any X- ray, examination, anesthetic, medical dental or surgical diagnosis or treatment and hospital care which is deemed advisable by and to be rendered under the general or special supervision of any physician, and surgeon licensed under the provision of the Medical Practice Act and any Dentist under the Dental Practice Act. If my child needs medical treatment (without valid insurance or ACCHS#), I (we) will assume financial responsibility for reimbursement to SIMC.

Insurance Company

Member ID number / Group number

ParentGuardian Signature*

Date*

Date

4. MEDICAL IINFORMATION AND PERMISSION TO GIVE MEDICATION

Please list any allergies and what happens if exposed.

Type N/A if not applicable.

Seasonal Allergies*

Food Allergies*

Insect or Bee Allergies*

Medication Allergies*

Other Allergies*

PLEASE LIST ANY MEDICAL CONDITIONS OR RECENT ILLNESSES THAT WE NEED TO BE AWARE OF*

MEDICATIONS: ALL MEDICATIONS MUST BE TURNED IN DURING REGISTRATION. Prescription Medications must be in the original container from the Pharmacy with the Dr.'s name and directions clearly visible on the label. Please list the Prescription and Over The Counter Medications your child has with him/her and needs to take during camp along with the instructions for giving them.

Name of Medication / Dosage & Time / Reason for taking (If none, type N/A.)*

In addition to the medications listed above, I give permission for SIMC staff to give the following medications that I have marked to my child as needed, according to the appropriate age/weight dosing:

Cough Drops or Cough Syrup (Guaifenesin)Tylenol (for pain or fever)Calamine Lotion for itchIbuprofen (for pain or fever)Bacitracin or other antibiotic ointment for wound care/infection preventionMallow for upset stomach

ParentGuardian Signature*

Date*

Date

* Emergency Phone Number*

Make non-refundable $110 check payable to "World Gospel Mission" and mail to SIMC Camp, 14202 N 73rd Ave, Peoria, AZ 85381 before Friday, May 23, 2025. ($120 includes Tshirt).

or

Pay online by going to SIMCamps.com/camp and click the pay online button.

Knowing there are dangers, hazards, and risks associated with Pinerock Camp & Retreat Center's activities including Archery, Climbing Wall, Low Ropes, High Ropes, Zip Line, Paintball, BB Guns, Swimming Pool, and/or related activities (hereafter "Activities"), and with sufficient knowledge of my experience, physical condition, and any and all limitations I may have at the time, I voluntarily assume all responsibility and risk of loss, damage, illness, injury and/or death that I may in any way sustain in connection with my voluntary participation in any and/or all of these Activities.

Understanding that I could be injured or die as a result of my participation in the Activities, I agree to release, indemnify and discharge Pinerock Camp & Retreat Center and their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (collectively "Pinerock") and hold Pinerock harmless on behalf of myself, my children, my parents, my heirs, assignees, personal representative and estate.

It is my intent by signing this document to agree not to make a claim or bring a law suit against Pinerock and to forever release them from any and all legal responsibility for any loss, injury, damage (including death) that I may suffer as a result of my participation in the aforementioned Activities whether due to negligence, default, action or inaction on the part of Pinerock.

Upon signing this form, I acknowledge and agree that I must abide by all rules, regulations, expectations, and standards of conduct applicable to participation in the Activities. I understand that Pinerock reserves the right to limit or terminate my participation in any activity, in the sole discretion of Pinerock staff.

I also herby grant Pinerock Camp & Retreat Center permission to use my likeness, which may appear randomly and without any intent to exploit me personally, in any photograph, video, or other digital media captured in the normal course of Pinerock's memorialization of activities at the camp, in any and all of its publications, including web-based publications, without payment or other consideration given to me.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT, WAIVER AND RELEASE AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Camper's Signature:

Date

Emergency Contact*

Emergency Phone #*

Relationship to camper*

PARENT/GUARDIAN CONSENT (to be completed if the participant is under the age of 18) I herby consent that my child may participate in Activities. I have read and fully understand the agreement, Waiver and Release and consent on behalf of the Participant to its terms.

Parent/Guardian Name*

Relationship to camper*

ParentGuardian Signature*

Date*

Date

SIMC

PARTICIPANT AGREEMENT, WAIVER AND RELEASE