Please indicate any medication the student is taking along with instructions including what time of day each medicine is needed. This can include prescriptions, emergency medicines, and any OTC medicines not provided by the clinic. If your student requires no medications please write "None"
Please list health insurance company/ and Id #.
Impact Camp, Christian Community Church North, Garden Church, Mountview Christian Church, River of Life, The Camp Nurse, The Connection, Gracetown, Judah Christian Community Church, Christian Fellowship Church and Heartland, hereinafter collectively referred to as the “Camp”, requires a signed application for all attendees of the Camp all to participate in Camp and any Camp activity including, but not limited to, transportation to and from, Challenge/Ropes Course (highs and lows), Zip Line, Water Toys, Mud Pit, Soccer, Basketball, Volleyball, and all other recreational sports and activities (“Camp Activity”). Furthermore by signing this form you release the Camp to photograph and/or use photographs of you or your child for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and activities of Camp. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to attend Camp and to participate in any Camp activity. Attendance and Activities at Camp may include warms-ups, games, group initiative problems; high and low challenge course, and/or other rigorous physical adventure activities as well as exposure to the elements, nature, and insects. The Camp takes all reasonable precautions to ensure you a safe and enjoyable experience. Parts of the experience, by their nature, can be physically demanding and include varying levels of stress and anxiety, not all of which can be foreseen. The decision to attend the Camp and the decision to not participate in any Camp activity at any level IS FIRST AND FOREMOST THE CHOICE OF THE ATTENDEE/PARTICIPANT AND HIS OR HER PARENT/GUARDIAN and if there is attendance at the Camp and participation at any level of any Camp activity, there is a risk, which must be assumed by each attendee and by each
participant. Although it is the Camp’s goal to maintain the physical, emotional and social safety of each attendee and participant of the Camp, the physical, emotional and social risks must be assumed by each attendee and participant.
“I understand that attendance at the Camp and participation in any Camp activity may be physically and emotionally demanding. I recognize the inherent risk of physical and/or emotional injury of attending Camp and participating in any and/or all Camp activities. I understand that each participant must assume the risk of any injury, physical and/or emotional, and any financial responsibility that could result from attending Camp and participating in any Camp Activity. I agree to assume such risks and such responsibility. I, on my behalf, and on behalf of my heirs and assigns, hereby release, indemnify and hold harmless Impact Camp, The Camp Nurse, Christian Community Church North, Garden Church, Mountview
Christian Church, River of Life, The Connection, Judah Christian Community Church, Christian Fellowship Church and Heartland from any and all claims, physical and emotional, including bodily injury, that I may have that may be sustained in connection with my attending Camp and with my participation in any and/or all Camp activities.” If you feel that there are any activities in which you or your child/ward should not be involved, please describe for us on the form above. I understand the directors of the Camp reserve the right to dismiss, without refund, any camper whose influence is detrimental to the operation of the camp, as determined by the discretion of the directors. I understand that the use of alcohol, tobacco products, and illegal drugs is strictly prohibited at all Camp events. I have read (or had read to me) this complete document and I understand the information contained herein. I have freely and voluntarily agreed to the above statements. Please sign your name below to agree to the above expectations.