Summergize Medical Form

Summergize Medical/Code of Conduct Form
Event Information

Gone are the days of having to find someone to notarize your completed medical form, so welcome to the ALL NEW ONLINE GPC Medical Release Form.
Event Name*
Date*

MonthDayYear
Date
Participant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Sex
Child's Weight
Emergency Contact #1
Name*

First NameLast Name
Relationship to Participant*
Cell*
Please enter a valid phone number.
Emergency Contact #2
Name*

First NameLast Name
Relationship to Participant*
Cell*
Please enter a valid phone number.
Insurance Information
Does the attendee have insurance?*
Insurance Company*
Family Physician*

First NameLast Name
Insurance Company Address*
Subscriber Name*

First NameLast Name
Policy #*
Subscriber #*
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Phone #*
Please enter a valid phone number.
Subscriber Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History

** If the participant has been exposed to a communicable disease within two weeks prior to event, please have doctors approval to participate.
Any operations, illness , or injuries in the last year?
Please list the operations, illness or injuries here.
*Does your child have any physical or mental problems that Summergize Leaders should be aware of? *
Please explain.*
List any allergies your child has.*
If none, put N/A
Select the medications the Summergize staff or volunteers may administer.*

TylenolIbuprofenAntihistamineTumsSwimmer’s EarEpipenOther
Waiver of Liability and Medical Release
Participant's Name

First NameLast Name
Functions and Activities
I understand that participating in programs, recreation and other activities of GracePointe Church is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with these activities, including,
by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability
By signing this Permission and Waiver Form, I expressly warrant that this child named above or I, if I am a participant, am capable of withstanding both the physical and mental demands of these activities. I also expressly assume all risks to the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release the church and its ministers, leaders, employees, volunteers and agents from any claim that my child may have or that I may against them as a result of injury or illness incurred during the course of participation in these activities. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives or assigns may have against the church or its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless the church and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.

First Aid and Emergency Medical Treatment
I recognize that there may be occasions where the child named above or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of the church to seek and secure any needed medical attention or treatment for the child named above or me, if I am a participant, including hospitalization, if in the agent’s opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.
________________________________________________________
Code of Conduct
Guidelines and Discipline Policy

Camp participants are expected to exhibit appropriate behavior at all times while at camp. In order to provide all campers and staff with a camp experience that is safe and enjoyable, the following guidelines have been developed. A caring and positive approach will be taken regarding discipline. Camp Serve Team will reinforce appropriate behavior through positive reinforcement, firm statements and redirection of activity. All campers must understand and follow the guidelines set forth. Please review these guidelines with your child.

*Talk in a pleasant manner. Foul language, putdowns and bullying will not be accepted.
*Be safe! Always obey camp rules and serve team.
*Treat all equipment and supplies with proper care and respect.
*Show respect for the Summergize serve team and fellow campers.
*Behavior that is threatening to the child or others will not be permitted at camp.
*Have a positive attitude and have fun!

Listed below are the discipline procedures for campers who are exhibiting unacceptable behavior. Depending on the severity of the behavior, we may skip a particular step.

Step 1: - Verbal Warning
Step 2: - Time Out or time away from the group. During a time out a camper may have to sit out from activities including games, crafts, or special event.
Step 3: - Parent Notification. If a child persists in unacceptable behavior, a warning will be issued. The Camp Director or Serve Team Member will speak with the child and their parent/guardian.

Please review these rules with your child prior to the first day of camp. The serve team will review these rules with your child at the beginning of camp as well. Thank you in advance for your cooperation. We hope to have a great camp weekend!

If you have read and discussed the Summergize Camp Guidelines and Discipline Policy with your camper and completed the above medical form, please sign below.
Parent Signature

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Today's Date

MonthDayYear
Date

Summergize Medical/Code of Conduct Form

Event Information

Participant Information

Emergency Contact #1

Emergency Contact #2

Insurance Information

Medical History

Waiver of Liability and Medical Release

Code of Conduct