Name of Camper ____________________________Name of Parent/Guardian_______________________ Address________________________________________City_____________State________Zip________ E-mail Address ____________________Age of Camper_____ Grade in Fal ______ Male/Female_____ T-shirt Size: Please Circle~ Child 6-8 10-12 14-16 Adult S M L (THIS WILL BE THE SIZE YOUR CHILD RECEIVES) Home Phone__________________ Cel Phone___________________ Work Phone___________________ Alternate Emergency Contact if parent cannot be reached ___________________Number_______________ What church does the camper attend? ___________________________Pastor’s Name________________
Is Camper covered by medical insurance? Yes No if Yes, Name of Insurer_________________________ Policy Number ____________________________ Medical Information Food/Medicine Al ergies _______________________________________________________________ Medical Conditions ___________________________________________________________________ Medications to be brought to Camp (include name of medication and dosage) ______________________________________________________________________________________ Please circle any over-the-counter medications the Camp Nurse may administer: Oral Benadryl Benadryl Cream Tylenol Motrin Antacid Miralax I am requesting my child room with this SAME AGE friend _____________________________________
*requests will be considered. No guarantee is made. Counselor requests are NOT considered
In consideration for the opportunity to participate in camp activit
ies, the Participant (or parent/guardian if the participant is a
minor) acknowledges and accepts the risk of injury associated with participation in and transportation to and from the activity. The Participant (or parent/guardian accepts personal financial responsibility for any injury sustained during the
activity or during transportation to and from the activity. Further, the Participant (or parent/guardian) promises to indemnify, defend and hold harmless the activity sponsor or its agents, employees, volunteers, or any other representatives (collectively
referred to hereinafter as the “Sponsor”) for any injury related directly or indirectly out of the described activity or
transportation to and from the activity, whether such injury arises out of the negligence of the Sponsor or otherwise. If a dispute over this agreement or any claim of damages arises, the Participant (or parent/guardian) agrees to resolve the
mat er through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel of the
American Arbitration Association for final resolution. Description of Summer Camp Activities: Activities include, but are not limited to: canoeing, fishing, swimming and water
activities, group games, team building activities, and of -site activities. Signature of Parent/Guardian: ____________________________________ Date: ____________________
Parent Agreement: Please read and initial each line:
_______I understand that for the safety of my child, the campground is of limits to family or friends or anyone not a staf member of Kid’s Camp. If there is an emergency I will be informed immediately and if I need to contact my child concerning
an emergency I will do so through the Camp Director.
_______I understand that my child cannot make or receive phone calls while at ending camp. _______I understand that my child is expected to be present throughout the whole week of camp with no personal
interruptions (i.e. sports/music practice, vacation, etc.) so that staf can best minister to my child.
_______I understand that if my child cannot stay at camp due to extreme disregard for camp rules/violation of state laws, I will be required to retrieve my child with no continuation of camp activities and no refund of camp costs.
_______I wil hold up staff & children in prayer during camp. _______I understand if my child must withdraw registration prior to camp for any reason, I wil be refunded the registration fee minus $75 for processing.
DIGN ITAS P.O. Box 9, 8127 Forch, Switzerland / www.dignitas.ch / 1st edition / May 2010 T he organisation «DIGNITAS – To live with dignity – To die with dignity» was founded on 17 May 1998. Now, it has been in existence for already 12 years. During this time it has helped a total of 1,060 people to end their lives gently, safely, without risk and usually in the presence of family m
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