KIDZ CAMP

Student Name

First NameLast Name

Date of Event

Date

Sex (M/F)

Date of Birth:

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/legal Guardian Name:

Full NameRelationship

Parent/legal Guardian Cell:

Please enter a valid phone number.Format: (000) 000-0000.

Parent/legal Guardian Email:

example@example.com

Emergency Contact information other than Parent/legal Guardian:

Full NameRelationship

Emergency Contact Cell:

Please enter a valid phone number.Format: (000) 000-0000.

PARENT/LEGAL GUARDIAN'S STATEMENT OF PARTICIPATION, ASSUMPTION OF RISK AND RELEASE OF LIABILITY

ACKNOWLEDGMENT OF INHERENT RISKS

I certify that I am aware of the inherent risk associated with activities as well as the inherent risk of being on or off Church property. Notwithstanding, I hereby give my child permission to participate in all activities further. In consideration of Victory Church agreeing to accept the above-named child as a participant, I hereby personally assume all risk about my child's attendance and participation in the activities or special events at /with Victory Church.

ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY

If my child is injured on camp Property or during any church sponsored activities, both on or off site, I acknowledge that I shall be personally liable for and agree to pay all costs and associated expenses incurred about medical and or dental service rendered. To my child in response to said injury.

LIMITATION ON INSURANCE COVERAGE

I understand that my family/personal health and accidental insurance will be the primary coverage

RELEASE AND HOLD HARMLESS AGREEMENT

I agree to release and hold harmless Victory Church, its trustees, employees, volunteers and representatives for an injury, harm, or other damage by any occurrence about my child's participation in camp activities in any form of fashion. I further agree to release and hold harmless Victory Church, its trustees and employees, volunteers, and representatives from any claim by me or my family estate, Heirs or assigns out of my child's participation in activities hosted by Victory Church.

PRE-AUTHORIZATION FOR MEDICAL TREATMENT

I hereby authorize any medical and or surgical treatment, including but not limiting to hospital care, to be rendered to my child as needed in the judgment of the treating physician who is chosen by the pastor or any employee working under him or her circumstances. Fire I further authorized to render first aid and to administer medication as prescribed and programmed on the dosage and frequency chart executed by the parent or guardian.

NON-PRESCRIPTION MEDICATIONS

I give my permission to the church's health supervisor or other Health Center staff to administer non- prescription over the counter medications to my child based on symptoms (Not a diagnosis). For example, but not limited to, Tylenol or ibuprofen, for mild fever or pain, Benadryl, or Claritin, for allergy symptoms; Pepto-Bismol, for diarrhea, cortisone cream for bug bites, calamine, for Poison Ivy, and so on.

ACKNOWLEDGMENT OF RESPONSIBILITY FOR DAMAGES

I agree that I am financially responsible for any damage to camp or bus property caused by my child, including any acts of graffiti.

CONSENT TO ADDRESS DISIPLINARY PROBLEMS

the above-named participant agrees to obey and observe all rules and to fully cooperate with the adult leadership, staff, and other participants I agree that if in the judgment of the adult leadership and /or staff my child becomes a discipline problem my child may be sent home at my expense.

USE OF CHILD’S PHOTOGRAPH FOR PROMOTIONAL PURPOSES

I agree and consent that my child's photograph may be used for promotional purposes or publicity material by Victory Church.

I acknowledge that I am the parent or authorized guardian of the above-named child. By my signature below I acknowledge that I have read and understand the information set forth above including the release and hold harmless agreement.

I Agree to terms & conditions

Signature

Date of Signature

Date

INSURANCE INFORMATION

Date of last tetanus shot:

Date

MEDICATIONS

1. All medications must be properly labeled and kept in original containers. Check expiration dates. No expired medications will be given.

2. All Prescription and non-prescription medications must be presented to camp health center personnel upon arrival at Victory Church.

3. All medications must be stored and dispensed from the event nurse( except EpiPen's or emergency inhalers) participants are not allowed to keep or self-administer any medication in accordance with Texas Department of State Health Services regulations.

4. Diabetics must bring a copy of their diabetes Management plan.

5. Non-prescription medications such as vitamin supplements or pain relivers will be given only according to the age and dosage restrictions and instructions listed on the package unless a doctor's order is provided.

6. EpiPen's or emergency inhalers may be kept with the participant (please send an extra one to be kept with the event nurse.) Event nurse personnel must be notified immediately when participant uses an EpiPen. If Asthma symptoms are not completely relieved the participant must be brought to the event nurse for evaluation.

7. List any medical problem, medical alert, allergy, or other relevant health concern/issue under general health information.

8. List all medications, dosage and intake after breakfast, lunch, dinner or bedtime on the medication dosage and frequency chart.

9. Place all medications and a copy of page 2 of this form in a heavy-duty, gallon sized zip-lock bag with the participant's name written with a permanent black marker on the outside of the bag.

Student's Name with Medication

Full NameAge

MEDICATION DOSAGE & CHART
Place all medications and copy of this page in heavy-duty, gallon sized zip-lock bag. Print the camper's name on the outside of the bag using a permanent black marker.