Microsoft word - 2014 trifold app no merge

______________________ ______________________ 2014 Dates Camp
Name Week
Registered
(T1) Teen
(T2) Teen
(J1) Junior
(J2) Junior Camp 2 Ages 8-12
Camp Horizon 7369 SUNNYSIDE DR LEESBURG, FL 34748 PARENT AND CAMPER AREEMENT (READ CAREFULLY BEFORE YOU SIGN)
The following is understood and agreed to by the camper and the parent or guardian signing below:
1. The camper applying to Camp Horizon is in good physical and emotional health and willing to submit to camp authority, standards of behavior, and discipline.
2. The parent/guardian signing below is in legal custody of the child and is legally responsible for payment of the fees and any damages or other expenses incurred by the camper.
Conditions of custody, if applicable, will be fully communicated to Camp Horizon in writing. Please notify shared guardians of your camp schedule.
3. Camp Horizon is empowered to obtain emergency medical/dental treatment for the camper if necessary. All healthcare expenses are the responsibility of the parent.
4. The health counselor (RN,LPN,Paramedic) may provide first aid and administer prescription and non prescription medications according to policy (see formulary pg 1).
5. Camp Horizon has permission of the camper’s parent/guardian to take the camper on supervised trips off the Camp property including but not limited to: canoe trips, sailing trips,
hikes on neighboring property, health-care visits, or other supervised outings unless notified otherwise in writing. 6. If the camper violates any Camp Horizon Standards of Conduct, (copy on the website and on request), or engages in any activity which the Camp believes is, at the sole
discretion of the Camp, inconsistent with its principles, the camper may be required to leave the Camp immediately. The parent/guardian will be required to come pick up the
camper at the earliest possible time. Fees are non-refundable if campers are sent home for disciplinary reasons.
7. We take cabin photos and both video and still pictures of campers in action. Cabin Photos are published on the web. Pictures of activities are used for promotional purposes without any financial reward to the subject(s). 8. We provide an address list to campers and staff that participate each week unless you notify us in writing otherwise or put a line through this statement and initial it.
9. All camper belongings are subject to inspection. Items that are not allowed at camp (i.e. cell phones / audio players) will be removed and placed in safe storage.
10. I/We release Evangelistic Horizons Unlimited Inc., its officers, employees, vendors (including but not limited to Climb Eagle Rock), and volunteers from financial responsibility
for injury sustained by my child while at Camp Horizon. Any claim or dispute arising from or related to this agreement shall be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker® Ministries (complete text of the Rules is available at www.HisPeace.org). SPECIAL CONSENT FOR
WATER-SKI / TUBING AND / OR WALL-CLIMBING
I/We, the parent or legal guardian of the camper named above and the named camper ac knowledge that there are certain inherent risks associated with the sport of water-skiing / tubing or wall climbing and that we accept the consequences of those inherent risks. Further, we understand that the named minor must observe and obey the camp rules pertaining thereto and agree not to act in a reckless manner while participating. I/ We give our consent for the named minor to participate in the water-ski / tubing program of Camp Horizon and/or Wall Climbing experience. (If you did not select skiing or wall cli mbing on initial registration this allows you or your child to add it later).
If you DO NOT give permission for your child to water-ski or tube and/or wall clim
bing please initial the applicable statement(s) below. My child DOES NOT HAVE permission to water-ski / tube. __________ My child DOES NOT HAVE permission to participate in Wall Climbing. __________
Signature of CAMPER "I agree to follow Camp Horizon's standa
The Camper
Parent or
Legal Guardian
Signature of PARENT or GUARDIAN HAVI
MUST SIGN
NG LEGAL CUSTODY
*ID CODE: This is your telephone password. It identifies YOU as the caller inquiring about your child.
PARENT/GUARDIAN/TRANSPORTATION CONTACT INFORMATION Name of person picking camper up (if other than parent or guardian) [ ] PAYMENT BY CHECK ENCLOSED (ENVELOPE RECOMMENDED) [ ] PAID ONLINE [ ] SEND INVOICE Evangelistic Horizons Unlimited, Inc
SUMMER CAMP 2014
Grade Entering
next fall
__________________________________________________ [ ] I have Health Insurance [ ] No Health Insurance
Registration E-mail address Please provide a copy of your health insurance card
ALL DISCOUNTS EXPIRE ON MAY 31 – SO PLEASE REGISTER EARLY
Enter $250 for one week or $490 for two weeks ($10 2nd week discount) [ ] Camp Wk 1 ($35) [ ] Camp Wk 2 ($35) [ ] Both Weeks ($70) [ ] Camp 1 ($35) [ ] Camp 2 ($35) [ ] Both Camps ($70) Location: [ ] Pembroke Pines [ ] Palm Beach Gardens
Camp Tuition, Activity Fees (Climbing Wall & Ski ), & Transportation Pre-Paid Spending Money
Minimum Payment: $75 non-refundable deposit for each week of camp
[ ] $25 Full Payment BY MAY 31; [ ] Bring A Friend Challenge Please Pay FINAL BALANCE at least 2-weeks prior to the first day of
Camper Health Information
each week of camp you are registered to attend.
[this section is required for all campers] Allergies to medicines or foods: _______________________________________________________________________________ Describe any physical or behavioral special needs: __________________________________________________________________ Camper is being treated for, or may have problems with (please circle all that apply & attach an explanation if needed):
Heart Tonsils Hay Fever Ears Hernia Sinuses Diabetes Skin Problems Asthma/Breathing Bed wetting Behavioral Issues
[ ] See attached notes / documents
SPECIAL CARE: [ ]-Contacts [ ]-Glasses [ ]-Braces [ ]-Retainer [ ]-Other
All medications must be checked in with the Camp Nurse/Medic who will administer them as prescribed. Provide clear written instructions to be given to the
health counselor at registration with all medications in a zip-lock bag. Prescription drugs must be in their original labeled containers. Over the counter
medications (vitamins, minerals, etc) must be in their original bottle with complete instructions for use. Asthmatic campers may keep their inhalers – you may
choose to send a backup inhaler to leave with the health counselor. Topical creams, eye drops or ear drops may be kept in the cabin if appropriate. If your
camper has any special needs please attach a note that explains this in detail.
I (parent/guardian) give permission for the Health Counselor (RN, LPN, Paramedic) to administer over-the-counter medications or a generic equivalent. (This
section is an addendum to the PARENT AND CAMPER AGREEMENT.) Below is the current formulary for the camp infirmary.
For Pain / Fever: Acetaminophen
Topical:
Antibiotic Ointment (Neosporin, Bacitracin, Polymixin) Antihistamine: Benadryl
Expectorant:
Eye Care:
Gastrointestinal: Emetrol
Antacids (i.e. Tums, Mylanta, or Maalox) Fungus: Lotrimin
Sore Throat:
Swimmer’s Ear:
Lice: “Rid”
***Children MUST be free of lice on arrival ***
The parent/guardian is responsible to provide adequate medical insurance and will be responsible for any and all medical bills incurred due to illness or injury of
the camper. Please attach a copy of your insurance card (both sides) This is helpful if off-site care is required.

Source: http://www.brianandruth.net/dnn/portals/2/Summer%202014/2014App.pdf