HYC ~ Camper Registration, Waiver & Release Form
DOB:___________ Grade (FALL 2013): ______ Sex: ______ T-shirt Size: S M L XL 2X 3X 4X Parent/s: _________________________________________________________________________________
Camper Address: __________________________________________________________________________ Home Phone: ________________________Parent Cell Phone: _________________________________ Parent Work Phone: ________________________Home Church: _______________________________ Parent Email: _____________________________ Camper Email: ________________________________
Last TETANUS (year) _________ immunizations current? Yes No Does camper have any allergies or medical conditions (Drugs, Food, Environmental)? Yes No If yes, explain in detail: ___________________________________________________________________
Medical Insurance Provider & Policy #: ___________________________________________________ Will the camper need to take medication while at camp? Yes No
MEDICINES MUST BE SENT IN THE ORIGINAL CONTAINER!! THIS INCLUDES ANY NON-PRESCRIPTION DRUGS.
Medical staff will not allow any medication to be taken in a manner different than what the container instructs.
All medicines, prescription AND nonprescription, will be dispensed by the camp medical staff. State law requires that medicine be kept in the infirmary. Campers will
not be allowed to keep their medications with them.
Over-the-Counter Medications The camper named on this form may be given the following, as needed (please check all that apply). __ Acetaminophen (Tylenol)
__ Diphenhydramine Oral or Topical (Benadryl)
__ Cough medicine (Guaifenesin/and or Dextromethorphan)
All over-the-counter medications will be given according to package instructions.
Does the camper have any special physical, mental, or emotional needs? Yes No
If yes, please list and give details. This form will be kept in strict confidence. Include any and all conditions or diagnosis, such as Diabetes, Asthma, ADD/ADHD, Depression, Bipolar, OCD, Anxiety, Oppositional Behaviors, etc. Please include any information that will help the camp staff provide the best possible camp experience for your child. ____________________________________________________________________
Would you like a call from the camp director or medical personnel regarding your child's needs? Yes No
RELEASE: I, parent or guardian, hereby give approval for my child to attend the Heartland Youth Camp at Camp Palestine and relieve the Heartland Youth Camp, the Kansas City Church of Christ, the Camp Palestine, and all the affiliated staff from any and all liability for sickness, accidents, or injuries while attending or being transported to/from the camp facilities. In the event of an emergency and I cannot be contacted, I give my consent to the Camp Director and/or the Camp Medical Personnel (Nurse) to authorize medical help on site or at an appropriate medical facility. ____________________________________________________________________________________________________ Parent or Legal Guardian (print) Signature of Parent or Legal Guardian Date
NOTE: NO CAMPER WILL BE ALLOWED TO CHECK IN AT CAMP UNLESS THIS SIGNED WAIVER IS TURNED IN.
Please mail form to Kansas City Church of Christ, 10250 Quivira Road, Lenexa, KS 66215 or fax to (913) 599-6377
Please fill in both sides of this form completely and return to West London Alliance Church with complete fees. Registrations may be mailed to 750 Wonderland Road North London, ON N6H 4K9. Upon receiving your application, an information package and receipt will be sent to you. If you have any questions concerning WIRED Registration, please contact the church at (519) 471-8716. See you i
This page to be retained by client Elderly Vaccination Subsidy Scheme (EVSS) 2011/12 Information about Seasonal Influenza Vaccination and Pneumococcal Vaccination Benefits of Getting Seasonal Influenza Vaccination and Pneumococcal Vaccination Infection of the airway such as those caused by seasonal influenza virus and pneumococcus is common. Once elders are infected, they are