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Strength of HIS Hands Camp Application
June 17th-19th , 2011
(for campers ages 7-16)
Name of camper: ________________ Nickname : __________ Age: ______
Sex : __ Race: ________ Date of birth: _______ Home Phone (___)________
Home address: ________________City: __________State:________Zip:______
Mailing Address (if different) :_____________________________________
Parent/Guardian email address: ___________________
Father’s name ________________ Cell # :______________
Mother’s name: _______________ Cell #: _____________
Guardian/Agency name: ___________________ Cell #: __________
Parents/Guardians/Agency address and number if different from camper:
Address: _________________________ Phone: (___) ________
Email address:________________________ Shirt Size:___________
Medical Information:
List TWO people not listed above who can be contacted in case of an emergency
(include address and telephone numbers)
1. ___________________________________________________________
_
2. ___________________________________________________________
Medications currently taking: ________________________________
Reasons for medication: __________________________________
**Medications MUST be in their original containers. Attach a separate
sheet detailing when medications should be taken, doses, etc…**
Date of last physical exam:_____________ Last tetanus booster shot: ________
Physician’s name: ________________________ Phone: ________________
Is camper insured? _______ Company name: ___________ Policy #: ________
Please answer Yes or No to the following:
Is camper allergic to bee stings?__Poison Ivy/Oak __Foods?__Sunscreen? __
Other? ______________________
What do we do in case of an allergic reaction to items above? __________
____________________________________________________________
Is campers shot record current?__If not, what is missing and why? _______
_____________________________________________________________
List all medications to which camper is allergic: ______________________
____________________________________________________________
Is camper currently receiving therapy or attending any special ed. Classes? ___
If yes, explain:________________________What agency? ______________
Counselor’s name:_____________________ Phone: ________________
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Medical Release (this MUST be signed before application is processed)
Strength of HIS Hands Ministry has my permission to obtain medical treatment and care for
________________________ (child’s legal name) as needed while under the supervision of
Strength of HIS Hands Ministry Camp according to the discretion of the camp personnel.
______________________________ _______________
Parent/Guardian Signature Date
Additional Information
Has your child ever attended camp before? __________________
Name of Camps_____________________
Has camper spent time away from home before?_____________
Grade in school next year? ____________
Is camper deaf or hearing impaired? ___________
Indicate your child’s mode of communication: Sign Language ___ Speech ___ Oral ___ Other
_________________
Can camper swim? ________ Complete a ropes course? __________
Is there any other information that we should be aware of about camper? ____
What are some of the campers interests/ hobbies?
_______________________________________________________________
Consent Form
The following MUST be signed before application can be processed
I / We agree in this covenant that I / We will indemnify, protect, and hold
harmless Strength of HIS Hands Ministry Camp, Staff, Volunteers, and Board
Members from and against any and all losses, damages, injuries, claims,
liabilities, suits, actions, judgments, and costs which might arise from or grow out
of any camping, sports, activities, or traveling while _____________________
(child’s legal name) is attending Strength of HIS Hands Ministry Camp. Camper
Insurance will pay only if there is no existing family or school insurance policy for
this child. Benefits under this policy are limited to amount set by insurance
company. Policy will not cover pre-existing conditions or illness. I, the
undersigned, am responsible for disclosing, in writing, at the time of check-in,
any medical changes which have occurred since the completion of this
application. I also agree that pictures and videos of my child taken at camp may
be sued to promote Strength of HIS Hands Ministry Camp.
____________________________________
Signed- Parent/Legal Guardian Date
Return application to: Strength of HIS Hands Ministry
Attention: Application Department
210 Phillips Drive
Forest City, NC 28043
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MEDICATION INSTRUCTIONS FOR : _SOHH Camp 2011
Morning:
Name of Medication Time to be Taken Taken with Something/
Empty stomach
1.
2.
3.
4.
Afternoon:
Name of Medication Time to be Taken Taken with Something/
Empty stomach
1.
2.
3.
4.
Evening:
Name of Medication Time to be Taken Taken with Something/
Empty stomach
1.
2.
3.
4.
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Strength of His Hands Summer Camp 2011
Camper Permission Slip
I ______________________________ (Parent/Guardian name) give
permission for Strength of HIS Hands Ministry to use pictures of my child,
______________________on their website, and in pamphlets, scrapbooks,
and newspapers, to help show others the activities that children will be
experiencing at camp. I understand that these pictures will only be used to
help advertise the camp, and will be used for this sole purpose.
_____________________________
(Parent/Guardian Signature)
_______________________
(Date Signed)
Strength of HIS Hands 2011 Release Form
I ______________________ , parent / guardian of Camper
______________________________ do hereby release Strength of
HIS Hands from any liability for injuries received during Camp
2010. I understand ahead of time that Campers will be engaging in
various activities that could result in an injury, such as:
swimming, horseback riding, day trips, and games. I have
provided copies of my insurance information that will be used in
case of an emergency to treat my child.
___________________________
(Signature of Parent/ Guardian)
____________________
(Date)