CAMP 2024: CAMP 4

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STUDENT NAME* This field is required.
First Name
Last Name
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STUDENT GRADE* This field is required.
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GENDER AT BIRTH* This field is required.
Male
Female
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STUDENT BIRTHDATE* This field is required.
Date
Month
Day
Year
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STUDENT CHURCH NAME & CITY* This field is required.
CHURCH NAME
CHURCH CITY
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EMERGENCY CONTACT NAME* This field is required.
First Name
Last Name
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EMERGENCY CONTACT PHONE NUMBER* This field is required.
Please enter a valid phone number.
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EMERGENCY CONTACT EMAIL ADDRESS* This field is required.
example@example.com
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ALLERGIES
Medication Allergies
Other Allergies
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DATE OF LAST TETANUS SHOT
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INSURANCE INFO
Insurance Company
Policy #
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MEDICATIONSPLEASE NOTE: **Our Medical Personnel can only dispense medications in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, and the dosage and frequency of administration. Please List ALL medications including over-the-counter or non-prescription drugs and vitamins) that are taken routinely. Send medication to last the entire duration of camp; no more, no less.
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MEDICATIONS CONTINUEDI give permission for the on-site medical personnel to administer the following medications to my child when necessary:
Tylenol (Acetaminophen)
Advil (Ibuprofen)
Benadryl (Diphenhydramine)
Aspirin
Pepto Bismol
Anti-Acid
Cough Drops
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PARENTAL PERMISSION* This field is required.This application and any health history provided herein are correct and complete. I authorize any minor child of mine herein named to engage in all activities and events, except as expressly noted. I authorize Penn-Del Ministry Network (“Penn-Del”) and any of its volunteers, employees, or affiliate churches, their volunteers, or employees to provide for any routine health care, administration of prescribed medications, and emergency treatment for me or my child, as may be deemed reasonable, within the sole discretion of Penn-Del, including but not limited to, x-rays, medical tests, treatment, or hospitalization. I agree to release to Penn-Del any medical or billing records necessary for treatment referral, billing, or insurance purposes. I acknowledge and consent that Penn-Del, its affiliates and vendors may take photographs and video images of me or my child during any event for use in advertising or any other purpose, including but not limited to, brochures, videos, and for use on the internet. I acknowledge that participation in the activities and events named or described above involve risk to me and my child, and may result in various types of injury, including but not limited to, sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activities and events named or described above, I, for me and my child, assume the risks of injury associated with participation in the activities and events. Additionally, I, for me and my child, assume the risk of exposure to COVID-19 and all its variants. I, for me and my child, accept personal financial responsibility for any injury or other loss sustained during the events and activities, as well as for any medical treatment rendered to me or my child provided by Penn-Del or any of its volunteers, employees, or affiliate churches, their volunteers, or employees. Furthermore, I, for me and my child, release and promise to indemnify, defend, and hold harmless Penn-Del or any of its volunteers, employees, officers, or directors or affiliate churches, their volunteers, employees, officers, or directors for any injury or loss, arising directly or indirectly, out of the activities or events named or described above or from transportation to and from the activities or events named or described above, whether such injury or loss arises out of the negligence of Penn-Del, or any of its volunteers, employees,officers, or directors, or affiliate churches, their volunteers, employees, officers, or directors. If any claim for damages should arise related to any of the activities or events named or described above or any dispute develops over the interpretation of this Consent and Release of Liability, I, for me and my child, agree that all such disputes shall be resolved exclusively by arbitration in accordance with the rules of the American Arbitration Association. If you agree with the above Consent and Release of Liability and intend to be legally bound, please sign prompt with your signature.
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