Refuge Summer Camp Registration

Student Name*

First NameLast Name

Date Of Birth*

Date

Gender

MaleFemale

Grade Level for 2021-2022 School Year*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

Emergency Contact*

First NameLast Name

Emergency Contact Relationship

Emergency Contact Phone*

Area CodePhone Number

The information provided on this form will be used for kitchen staff about nutritional needs, cabin leaders and director, as well as the nurse for health background of your child.

Insurance Provider and Policy Number*

Are the campers immunizations up to date, including tetanus shot?*

YesNo

If camper requires medication during camp, please list medication name, dosage and frequency.

If the camper has an allergy or special dietary need please list all foods, medications, and substances below

If the camper has any chronic health concerns please list them below and give normal treatment details (e.g. asthma, hearing difficulties, insect stings, fears/phobias, headaches, heart condition, seizure disorder, sleep walking, diabetes, bedwetting, fainting).

COVID-19 Disclaimer

At this time, the 2021 summer camp will take place as planned. However, if you are sick or feeling you are getting sick, we ask that you please stay home.

Currently, older adults and persons with underlying health conditions are considered to be at increased risk of severe illness and complications from COVID-19. Examples of underlying health conditions include heart disease, lung disease, diabetes, people with weakened immune systems, and people who are pregnant. The CDC recommends that people in high-risk groups consult with their healthcare provider about attending any large gathering.

If you do choose to attend, please keep in mind the CDC recommendations on how to keep yourself and others healthy:

· Avoid close contact with people who are sick.

· Avoid touching your eyes, nose, and mouth with unwashed hands.

· Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available.

I acknowledge and agree to the following:

· I am aware of the existence of the risk in my in-person participation to this event and that may cause illness such as, but not limited to COVID-19 that may lead to flu like symptoms or even death.

· I am aware that I must notify Grace Church if I experience symptoms relating to COVID-19. Such as fever, fatigue, or difficulty in breathing, within 14 days of the event or anytime during.

MEDICAL ANDLIABILITY RELEASE: (You may sign your own release is you are 18 or older) By Signing this you acknowledge that you have read the terms and conditions and verify that the health history is correct. The undersigned does hereby give permission for my child, to attend and participate in activities sponsored by Grace Evangelical Free Church for the date of June 28th - July 2nd 2021. I will not hold Grace Evangelical Free Church and its agents, the campground (Koinonia Conference Grounds) and its agents liable for injury caused by common accident, illness, or the rendering of emergency care. If I cannot be reached in an emergency, I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examinations, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Grace Evangelical Free Church. By also signing this document, the undersigned gives permission for my child’s likeness in the form of still picture and/or video and audio to be used in any church sponsored promotional material.