2018 2000 Strong Camp Registration and Health Form

2000 Strong Adventure Camp

Registration and Health Form
Camper Information
Full Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Grade Completed
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
Cabin Mate Request
Parent/Guardian with legal custody to be contacted in case of illness of injury
Name*

First NameLast Name
Relationship to Camper*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
How did you hear about us?*

2000 Strong WebsiteJCRB WebsiteFacebookFriendOther
Medical Information
Does the camper have any known allergies, chronic illness or other medical conditions? If yes, please describe.
Does Camper have any known allergies to the following

SunscreenBug SprayBoth
Please list all medications (including over-the-counter or non-prescription drugs) taken routinely.
All medicine must be in its original container identifying the prescribing physician (if a presciption), medicine name, dosage and frequency of administration; otherwise, we will be unable to dispense the medication to your child. Please bring enough medicine to last the entire camp. All medicines must be turned over to the Camp Health Officer during check-in.
Does the camper have any dietary restrictions? If yes, please provide instructions.
General Health History (please check all the apply)
Has/Does the camper

Ever been hospitalized?Ever had surgery?Have recurrent/chronic illnesses?Had a recent infectious disease?Had a recent injury?Had asthma/wheezing/shortness of breath?Have diabetes?Had/Have seizures?Had/Have recurrent headaches?Wear glasses, contacts or protective eyewear?Had fainting or dizziness spells?Passed out/had chest pain during exercise?Had mononucleosis during the last 12 months?If female, have problems with menstruation?Have problems with falling asleep/sleepwalking?Have a history of bedwetting?Ever had back/joint problems?Have problems with diarrhea/constipation?Have any skin problems?Traveled outside the country in the past 9 months?
Please explain any conditions checked above, or list any additional medical issues
Mental, Emotional and Social Health (please check all the apply)
Has/Does the camper

Ever been treated for Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (AD/HD)?Ever been treated for emotional or behavioral difficulties or an eating disorder?During the last 12 months, seen a professional to address mental/emotional health concerns?Had a significant life event that continues to affect the camper's life? (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
Please explain any conditions checked above, or list any additional mental, emotional or social issues
Immunizations
Are the camper's immunizations up to date?*

YesNo
If you checked "No" in the previous question, please check the statement below.

I understand and accept the risk to my child from not being fully immunized.
A copy of the camper's immunization record may be uploaded here

Upload a File

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Physician and Insurance Information
Family Physician

First NameLast Name
Business Phone

Area CodePhone Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the camper covered by family medical/hospital insurance?*

YesNo
You may upload a copy of your insurance card here or enter the information below.

Upload a File

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Insurance Card Information
Insurance Company
Group Number
Policy Number
Insurance Company Phone Number
Name of Insured
Birthdate of Insured
Relationship to Insured
Consents, Releases and Waivers
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to 2000 Strong for Christ and the YMCA to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Camper Activity Consent

I hereby consent to the above named camper participating in all activities offered by the 2000 Strong Adventure Camp including, but not limited to: camping, boating, swimming, hiking, rock wall climbing, riding the zip line, archery and sporting events. I have specified below any items from the preceding list for which I DO NOT give consent for the above names camper to participate. I also agree that the above named camper has the necessary skills to participate in the approved activities.
Release and Waiver of Liability and Indemnity Agreement

Whereas the undersigned parent, legal guardian, next of kin, on behalf of himself or herself, his or her personal representatives, heirs, and next of kin, camper, child (herein referred to as "Applicant") or participant acknowledges that even though every effort is made to provide a safe accident-free environment, incidents may occur. In consideration for the camper listed above being accepted by the 2000 Strong Youth for Christ Staff for participation in this camp, I (Applicant) being 21 years of age or older, do for myself, ourselves, Applicant, (and for and on behalf of my child-participant, if said child is not 21 years of age or older) hereby release, forever discharge and agree to hold harmless the aforementioned 2000 Strong Youth for Christ Staff and the Directors, Officers, Volunteers, Servants, and Agents (collectivlely the "Released Parties") Applicant hereby releases, waives and covenants not to sue for, and Applicant shall indemnify, defend and hold harmless 2000 Strong Youth for Christ and Released Parties thereof from and against any economic or non-economic losses, any and all liability, damages, suits, actions, claims and attorney's fees, costs, expenses, or demands of every kind and nature whatsoever, whether for bodily injury, porperty damage, death, or loss otherwise. Whether caused in whole or in part by the negligence, gross negligence or strict liablity of the released parties or otherwise to the fullest extent permitted by law arising from or alleged to have arisin from Applicant's presence, observation, use or participation at or in the 2000 Strong Adventure Camp , and or the presence, observation, use or particitpation of any family member, dependent or guest, including any minors, accompanying applicant at or in the camp. Applicant voluntarily agreess to indemnify, hold harmless, assume full responsibility for and defend the Released Parties from any risk of bodily injury, death, or property damage while Applicant, Applicant's Family Member , Dependent, or Guest including any Minor's accompanying Applicant are present in, observing, using or participating in the camp or arising out of or in any way connected to Applicants, Applicants Family Member, Dependent, or Guest, including claims or demands for personal injury, sickness or death as well as property damage and expenses of any nature whatsoever whether caused in whole or in part by the negligence, gross negligence or strict liability of the Released Parties or otherwise to the fullest extent permitted by law which may be incurred by the undersigned, Applicant, the child-participant that occur while said Child, Applicant is participating in the above described camp. Applicant assumes full responsibility for any items lost or stolen while Applicant is present in, observing, using or participating in the 2000 Strong for Christ Adventure Camp. Applicant also states that Applicant is not under the influence of any chemical substance, including but not limited to, medications, illegal drugs, and/or alcohol, at the time of execution of this Release and Waiver of Liability and Indemnity agreement, and will not be under the infuence of any chemical substance, including but not limited to medications, illegal drugs, and/or alcohol, during the ovservation, use,or participation in or at the 2000 Strong Adventure Camp. In addition, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further agrees to hold harmless and indemnify said organization, its directors, employees and agents for any liability sustained by said organization as the result of the neglegent, willful or intentional acts of said participant, including expenses incurred attendant thereto. Furthermore, in consideration of any child under the age of eight years old must be accompanied by a parent or legal guardian at any and all times including, but not limited to, sleeping in the same cabin as the parent or legal guardian while at 2000 Strong Adventure Camp. Applicant further expressly agrees that this Release and Waiver of Liability and Indemnity Agreement cannot be altered in any way, and is intended to be as broad and inclusive as permitted by Texas Law, and that if any portion of the Release and Waiver of Liability and Indemnity Agreement is held invalid, Applicant agrees that the balance shall, notwithstading, continue in full legal force and effect. Applicant fully understands that Applicant's entrance, observance, use, or participaton of, on, in the 2000 Strong Adventure Camp is entirely voluntary, Applicant has read and understood this Release and Waiver of Liability and Indemnity Agreement, has voluntarily signed this Release and Waiver of Liability and Indemnity Agreement, and argees that no oral representation, statement, or inducement apart from this written agreement have been made to Applicant.
Camper's Promise

To help make the camp a great experience for everyone, I will abide by the rules and expectations of the camp. I will live by the highest Christian standards or I will be sent home at the expense of my parent (s)/guardian. I will be on time to all activities and ready to participate. I will be courteous, kind and respectful of others and their possessions. I will refrain from abusive or derogatory language.

I will not bring tobacco, alcohol, drugs, knives, fire arms, fireworks, matches or cigarette lighters to camp.

I will not leave the campgrounds for any reason.

I WILL NOT BRING NON-PRESCRIPTION MEDICATION TO CAMP AND ALL PRESCRIPTION MEDICINE BROUGHT TO CAMP WILL BE IN THE ORIGINAL CONTAINER CONTAINING MY NAME. (ALL MEDICINE MUST BE TURNED OVER TO THE NURSE.)

I will live by the Golden Rule: Do unto others as I would have them do unto me.

(Failure to meet this policy will result in the camper being sent home at the expense of parent(s)/guardian.)
Photo Release

In consideration of the right of the camper listed above to participate in this camp, I hereby give consent and authorize the taking of photographs or videotape in which my child may appear. I herby waive all rights of privacy in and to any said pictures or tapes.
Please check to acknowledge that you have read and agree to the above consents, releases and waivers. By checking this box you are providing an electronic signature. An electronic signature will be equally as binding as an original manual paper signature.*

I Agree
Payment Choice 1 - Use payment choice 1 options below if you are paying by credit card at this time, after checking the desired fields below and hit submit you will be taken to paypal to complete payment.

Payment Choice 2 - Use payment Choice 2 options below if you do not wish to pay now or wish to pay by check please fill out the fields in Payment Choice 2. You will be able to purchase a Canteen Card and Tshirt at registration.
Payment Choice 1 Paying with credit card at this time.

Enter coupon code Earlybird to receive free tshirt until June 14

Adventure Camp$225.00

Tshirt$15.00

T-Shirt

Enter coupon

Total $0.00

Payment Choice 2
Use Options below if you are paying by check or credit card at registration or mailing your payment and do not wish to use paypal please do not enter the coupon code or check any of the fields above to make the following payment choices. Final payment must be recieved by July 1. if you are mailing a payment.
I will Pay at camp registration with Check or Credit Card. Note: Click on the yes and click submit, You will automatically be taken to paypal, If you are not paying just exit paypal and you will automatically be registered.

Yes
I will Mail Check to 2000 Strong for Christ P.O. Box 117024 Carrollton, TX 75011

Yes
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