2019 Camp Registration

Parent/Legal Guardian Information

Parent/Legal Guardian 1
Name *

First Name Last Name
Relationship to Camper(s) *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *

Confirmation Email example@example.com
Employer Information:

To help us reach you in case of an emergency. If you work from home, please include your home contact information.
Employer Name *
Employer Phone *

Area Code Phone Number
Employer Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Parent/Legal Guardian 2
Name

First Name Last Name
Relationship to Camper(s)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Employer Information:

To help us reach you in case of an emergency.
Employer Name
Employer Phone Number

Area Code Phone Number
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Emergency Contact/Authorized Pick-Up Information:

Contact must have a Colorado address

Emergency Contact Information
In the event of an emergency, and if we cannot reach a parent or legal gaurdian, please provide the name, address, and telephone number of another person we should contact. Being listed as an Emergency Contact will also authorize this individual to pick-up your child/children from camp.
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Emergency Contact Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Emergency Medical Contacts
Emergency Medical Contacts
Physician Name *
Physician Phone Number *

Area Code Phone Number
Dentist Name *
Dentist Phone Number *

Area Code Phone Number

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Authorizations

Please carefully read and consider the following authorizations.
Check "yes" to indicate your authorization or "no" to deny authorization for each of the following. By signing and submitting this registration at the end of the form, your selected responses are binding.

Image Authorization
Image Authorization:

Check yes to authorize Solid Rock Camp and Retreat Center to use video, photography, or other digital representation of you and your family members for the purpose of promoting Solid Rock Camp and Retreat Center in print and electronic media.
Image Authorization: *

Yes No

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Sunscreen & Insect Repellent
Sunscreen and Insect Repellent Authorization:

Over exposure to the sun and certain insect bites present potential health risks. If your camper(s) have specific sensitivities, we ask that you send them with the sunscreen and insect repellent that you use at home. Otherwise, Solid Rock Camp and Retreat Center will provide these items for campers. Please indicate if you authorize application of sunscreen and insect repellent, as needed, to your child.
Sunscreen Authorization: *

Yes No
Insect Repellent Authorization: *

Yes No

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Activities Authorization
Activities Authorization:

I hereby give my permission for my child to attend Solid Rock Camp and Retreat Center and to participate in all camp activities. I give my permission for this child to participate in any off-site activities, including emergency situations (if any) by authorized vehicles.

I will not hold Solid Rock Camp and Retreat Center or its agents liable for injury caused by common accident, illness, or the rendering of emergency care.
*

Yes
Please note any exceptions to activities authorization:

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Pickup Authorization
Release For Pickup Authorization:

It is the policy of Solid Rock Camp and Retreat Center to release campers at the end of camp only to the camper's parent, legal gaurdian, emergency contact, or other authorized person. Please list the full, legal names, contact phone number, and address of other individuals who are authorized to pick up your child.
Individuals Authorized for Pickup:

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Submission Page
Medications:

If there are any prescription or special over-the-counter medications that your child(ren) will need at camp, you must provide those. Each of the individual medications must be accompanied by a medication authorization form signed by both you and your child(ren)'s physician. This form is available for download on the camp registration page.

Emergency Care
Parental Consent to Medical, Dental, or Hospital Care:

In the event of an emergency, every effort will be made to contact you and your emergency contact. If we are unable to reach you and your child(ren) is in critical need of care, we need this medical authorization release to be able to seek out that care from local doctors and/or hospitals. Without this consent, it is not possible for your child(ren) to stay at the camp.
I consent for my child(ren) to receive, upon the advice of a physician and/or surgeon licensed under the Medical Practice Act, any x-ray examination, anesthesia, medical, or surgical diagnosis or treatment and hospital care.

This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis and/or treatment and hospital care by a dentist licensed under the Dental Practices Act.
I further agree to pay all charges for the dental, medical, or hospital care or treatment. As parent or legal guardian of my child(ren), I am responsible for the health care decisions of my child(ren) and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child(ren) is legally sufficient.

I understand that in the case of an emergency, every effort will be made to contact a responsible parent or gaurdian of the camper(s). In the event that contact cannot be made, I hereby give permission to the camp administration and the physician they may select to secure proper treatment for, to hospitalize, and to order such injections, anesthesia, or operations as may be urgently necessary for my child(ren). In the event of a claim, family insurance (if any) will be liable. I hereby authorize Solid Rock Camp and Retreat Center's medical supervisor to act as the prescriptive authority for my child(ren) while he/she is at camp. I understand that the doctor's standing orders are available for inspection upon request.
Do you agree to provide Solid Rock Camp with Emergency Medical Authorization as specified above: *

Yes

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By typing your name, you attest that the information you have provided is accurate to the best of your knowledge. *
Signature *

Clear
Today's Date: *
Next Steps:

The registration of your camper(s) is not complete until: 1. This form is submitted, 2. Your camper(s) immunization records have been received, 3. Medical Authorization Forms have been received, & 4. Payment for the registration has been received. Links to these forms are all available at www.solidrockretreat.com/camp-registration
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Solid Rock Camp Registration

Camper Information

Camper Information

Camper Information

Camper Information

Parent/Legal Guardian Information

Emergency Contact/Authorized Pick-Up Information:

Emergency Medical Contacts

Authorizations

Submission Page

Next Steps: