Trinity Pines Camp (Trinity, TX)

Kids who just completed grades 3-5

Registration Deadline: May 23, 2018

Costs

Sign-up:

Before April 1st: $319

April 2nd-May 23rd: $349

2017 Kids Camp Registration Checklist for Parents

**Everything is due by May 23, 2018**

Register and Pay Deposit Register online via link on HNW.org/kids website or https://event-9076-

abd8.echurchevents.com/step1.

Pay $60 deposit online when you register

-designate payment to Camps

Forms Student Life Participant Form

-Must be notarized

Copy of insurance card (front and back)

Medication Administration Authorization Form

-Required for anyone bringing medication or may need to receive over-the-

counter medication from Trinity Pines.

HNW Permission, Release, and Medical Authorization Form

HNW Parent Guardian Authorization, Waiver, & Consent for Over the Counter Med.

Return completed forms to Tiffany Moore by:

-dropping off or mailing them to 19911 State Hwy 249, Houston, TX 77070

-scanning them to tiffanyc@hnw.org

Additional Payments Pay remaining balance on Pushpay (https://pushpay.com/g/hnwpayments?src=hpp)

and designate your payment to Camps

Payments Due

Registration Date Deposit

(paid during online registration)

Additional Payment Due (via Pushpay link)

Total Cost

Registered before April 1st

$60 $259 $319

Registered between April 2-May 23

$60 $289 $349

STUDENTLIFEFORKIDS.COM • PO BOX 36040, BIRMINGHAM, AL 35236 • TEL: (800) 718-2267 • FAX: (205) 403-3969

PARTICIPANT FORMGroup Leaders: Bring TWO notarized copies of this document to Check-In. One copy must be notarized for Student Life For Kids and the other for Trinity Pines. YOU MUST attach a photocopy of insurance card (front & back) to both copies.

CHURCH INFORMATIONChurch Name:_____________________________________________________________________________________________________

Group Leader:_____________________________________________ Group Leader’s cell # at Camp: (_______)____________________

Church Address:___________________________________________ City:________________________ State:______ Zip:____________

PARTICIPANT INFORMATIONName_____________________________________________________________________________________________________________

Age:_______ Date of Birth:______/______/______ Grade Completed (campers only): ______________

Address:______________________________________________ City:_______________________ State:________ Zip:_____________

In case of an emergency notify:_______________________________________ Relationship to participant:_______________________

Mobile: (_______)____________________ Work: (_______)____________________ Other:(_______)____________________

MEDICAL PROFILEAre all immunizations current for your child: Yes No

Generally, the participant’s health is (Check One): Excellent Good Fair Poor

If Fair or Poor, please explain the condition:____________________________________________________________________________

List any medical difficulties currently being treated:______________________________________________________________________

Check any that cause you problems & explain:

Asthma Sinusitis Bronchitis Joint or Back Problems

Kidney Trouble Heart Condition Diabetes Emotional

Dizziness/Vertigo Stomach Condition Hay Fever Recent Surgery

Epilepsy Seizures Bleeding Disorder Other _________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Allergies (food, medications, insect sting, other):________________________________________________________________________

List any previous operations or serious illnesses:_________________________________________________________________________

List any medications you are currently taking:___________________________________________________________________________

List any special diet or special needs:_________________________________________________________________________________

Childhood Diseases: Chickenpox Measles Mumps Whooping Cough Other:________________________

Date of Tetanus Immunization: ______/______/______

YOU MUST ATTACH A PHOTOCOPY OF INSURANCE CARD (FRONT & BACK).If I or my child requires medical attention while at camp, I understand that I am responsible for the cost. If I or my child does not have insurance, the sponsoring church will be the financially responsible party. If medical attention is needed because of an acci-dental injury at camp, LifeWay provides a limited insurance policy that applies to those costs.

PERMISSION, ACKNOWLEDGEMENTS, RELEASE, INDEMNITYMy permission is granted for the camp or event director, church official, any camp or event staffer, or adult present or in charge of first aid, to obtain necessary medical attention in case of sickness or injury to me or my child. Also, I understand that as a Participant, I or my child may be photographed or videotaped during normal camp or event activities, and these photos/videos may be used for promotional purposes. I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and forever discharge LifeWay Christian Resources of the Southern Baptist Convention, the Student Life For Kids camp location, the Church, camp

Houston Northwest Church

Troy McDaniel 713 907-7835

19911 State Highway 249 Houston TX 77070

STUDENTLIFEFORKIDS.COM • PO BOX 36040, BIRMINGHAM, AL 35236 • TEL: (800) 718-2267 • FAX: (205) 403-3969

or participation in this camp or event. I agree to indemnify the Released Parties for any and all claims, demands, damages, injuries, costs, suits or causes of action, past, present, or future, arising out of or caused by myself or by my child while participating in this camp or event or while on property leased or owned by any of the Released Parties.

Assumption of Risk. I am aware of the risks associated with participation in the above event and do hereby voluntarily assume full responsibility for any risk of loss, property damage or personal injury, including death, that may result from participation in event activities.

Recreation. The recreation programs at summer event venues strive to offer fun, safe and challenging activities that engage the whole person—body, mind and soul. Program staff are trained and as a team committed to your rewarding experience with safety as their highest priority. They have done everything possible to mitigate any risks involved in their recreation programs. However there are inherent risks to participation in recreation activities, including but not limited to, initiative games, high and low challenge course, outdoor education, paintball and aquatics (not available at every venue). You could experience any of the following – elevated heart and respiratory rates, uncomfortable group dynamics, climbing or descending unpredictable and possibly slick or uneven terrain, crossing narrow wires and logs, jumping, running, climbing/descending steep rock faces, traveling long distances in remote settings, carrying weight on your backs and shoulders, unforeseen forces of nature or weather, any of which could result in injury/illness that could result in loss of life, limb and/or property. For more detailed information about the recreation programs offered at Student Life For Kids camp locations, go to studentlifeforkids.com and follow the specific link to the camp location’s information.

Understanding. I represent and acknowledge that I have completely read and understand this document and all itsterms and all matters referred to herein, and I signed voluntarily as my free act and deed, that I have had an ampleopportunity to obtain the advice of counsel and that, by signing this document, I understand that I am relinquishing legalrights and remedies that may have otherwise been available to me. I understand that this Waiver and Release shall beconstrued as broadly and inclusively as is permitted by applicable law and agree that if any portion of this document isheld invalid, the remaining shall continue in full force and effect. To the extent the restriction on filing lawsuits is deemedunlawful, I agree to submit any Claims to a Christian conciliation/mediation organization for binding resolution.

Affirmation. Participant affirms that he/she has not been convicted of nor received a deferred adjudication for: a misdemeanor or felony under any state or federal statute regarding crimes against persons, sexual offenses or violent offenses under the “Participant Name” submitted on this document or any other name or alias.

Copy to Camp Venue. It is understood and agreed that a copy of this form shall be treated as authentic and binding as the original and that a copy of same shall be provided to camp venue.

Complete and sign below (participants who are minors per your state statute require Parent/Legal Guardian signature).

Participant Signature:_____________________________________________ (only if 19yrs of age or older) Date:_____/_____/______

Parent/Guardian Signature:__________________________________ Phone:(______)__________________ Date:_____/_____/______

NOTARY ACKNOWLEDGEMENT:State of ___________________ County of _________________ on _________________ before me, ______________________________,

Notary Public, personally appeared ______________________________________________________________________________ who

proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the state that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

___________________________________________________ Notary signature

___________________________________________________My commission expires

Please place any notary stamp or seal here if applicable

GENERAL PERMISSION FORM, RELEASE & MEDICAL AUTHORIZATION FOR EVENTS ON AND/OR OFF CAMPUS

Child/Student Information: Today’s Date:

Last Name: First Name:

DOB: Age: M or F (circle one) Home Phone:

Address: City: Zip:

Mom’s Name: Mom’s Cell Phone: __________________________________

Mom’s Email: Dad’s Name: _____________________________________

Dad’s Cell Phone: _________________________________ Dad’s Email: ____________________________________

Name and number of person other than parents to notify in case of an emergency:

Insurance/Physician Information:

Insurance Co. Name and Address:

Hospitalization Policy #: Policy Issued under name of:

Family Physician Name/Phone #:

Medical Information:

Is there a history of: fainting spells? heart trouble? epilepsy? diabetes? asthma? sinusitis?

bronchitis? kidney trouble? dizziness? stomach upset? hay fever? other?

Allergies:

Does child/student have any special needs or medical conditions that HNW needs to be made aware of?

Y or N (circle one) If so what?

List any current medications:

List any previous operations or serious illness:

Immunizations: Current Not current (state the reason)

Tetanus shot? Y or N (circle one) Date of last tetanus shot:

Any special dietary needs?

(Form not valid unless signed and dated on following pages.)

CONSENT INFORMATION

I being the parent and/or legal

guardian of a minor child, hereby acknowledge that said minor

presently is under my care, custody and control for all events.

Should an emergency situation arise concerning my minor child which situation necessitates medical

or surgical attention and I are unavailable to give consent to such necessary treatment, I hereby give

my consent and permission to Houston Northwest Church to act on my behalf in authorizing

unexpected medical, dental, surgical care or hospitalization for the above named minor, and further

authorize any attending physician to make such decisions and to perform such decisions and to

perform such medical treatment(s) and/or surgical procedures and/or hospitalization upon the above

named minor, which may, in the professional opinion of said attending physician, be necessary and

proper under the circumstances of any emergency situation. I also give Houston Northwest Church

and its representatives permission to transport my child at their discretion in case of emergency.

When medical treatment and/or services are provided. I understand that information regarding my

insurance coverage will be made available to the providers of such services and that any and all

resulting expenses will be billed directly to me.

Initial ______

Initial ______

This consent covers all on/off campus events through December 31, 2018

This consent covers all on/off campus MDO events through May 31, 2018

____________________________________________________ _____________________________ Signature of Parent or Guardian Date

Photo & Video Consent

I understand and will allow photos and videos of my child to be taken while at this event to be used in any Houston Northwest Church publications. I also understand that publication of these photographs may be accomplished electronically via the Internet/World Wide Web and that after publication the church will be unable to prevent persons from gaining access to the Internet/World Wide Web, copying my photographs and video therefrom, and subsequently using, altering, or republishing it without my consent. I waive any claim for damages against the church from unconsented use, alteration, or republication of my photographs and video by third parties accessing the Internet/World Wide Web.

____________________________________________________ ______________________ Signature of Parent or Guardian Date

RELEASE/INDEMNITY AGREEMENT

I hereby expressly waive and release any and all rights which I and my heirs, executors and

administrators may have, against Houston Northwest Church (“Houston NW”) or its agents,

employees, representatives, volunteers, members, successors and assigns for any and all injuries

suffered, damages and/or medical expenses incurred by me that arise out of my presence with

Houston NW or at activities they have sponsored. I agree to hold Houston NW and its agents,

Employees representatives, volunteers, members, successors and assigns harmless from any and all

liability of any nature, which may arise from my participation or presence with Houston NW or at

activities they have sponsored. I acknowledge and recognize there are inherent safety/health risks

that exist by participating in any Houston NW outreach events or mission trips, specifically those that

require international travel.

I agree to defend, indemnify and hold Houston NW harmless for any claims and/or lawsuits brought

or filed against them by me, on my behalf, or my heirs, executors, and/or administrators which may

arise from my participation or presence with Houston NW or at activities they have sponsored,

including any claims for personal injuries, property damages, recovery of medical expenses and/or

death claims. MY DEFENSE AND INDEMNITY OBLIGATION(S) SHALL APPLY WHETHER OR NOT A

HOUSTON NW MEMBER, EMPLOYEE AND/OR VOLUNTEER MAY BE GUILTY OF ANY NEGLIGENT

ACT OR OMISSION, WHETHER IT BE SOLE OR CONCURRENT, OR THEY MAY BE STRICTLY LIABLE

FOR THE CONSEQUENCES OF ANY ACT OR OMISSION.

I hereby acknowledge I am of sound mind and that I have read and understand this agreement and

have willingly placed my signature below as evidence of my acceptance of all the conditions

hereinabove.

Signature of Parent or Guardian Date

Parent Guardian Authorization, Waiver, & Consent for Over the Counter (OTC) Medications

Over-the-Counter (OTC) Medication may at times need to be administered, if approval is indicated by the student’s parent or guardian. Please complete the following section to save time if your child needs any of these OTC medications during her/his stay. Note: Unless we have parental authorization, we cannot administer ANY medications.

I hereby authorize that the following medications may be given to (child’s name) if the need arises. You may dispense only those checked below.

☐ Ointments for minor wound care, first aid as directed.

(Antiseptic, anti-itch, anti-sting, antibiotic, sunburn) ☐ Throat lozenges and/or spray as directed for sore throat

☐ Tylenol/Acetaminophen as directed ☐ Ibuprofen as directed

☐ Micatin or anti-fungus treatment as directed for athlete’s foot

☐ Kaopectate or Imodium for diarrhea as directed ☐ Milk of Magnesia, Pepto Bismol, or Mylanta for upset stomach or nausea as directed

☐ Rolaids or Tums for acid reflux, heartburn, or indigestion as directed

☐ Actifed or Sudafed as directed for nasal congestion or allergy relief per instructions

☐ Medicated lip ointment for dry, chapped lips, lip blisters, or canker sores as directed

☐ Hydrocortisone ointment as directed for mild skin irritations, poison ivy, and insect bites

☐ Benadryl for swelling, hives, allergic reaction, as directed

☐ Visine or other eye drops for minor eye irritation

☐ Swimmer’s ear drops as directed

☐ Medicated powder for skin irritation as directed

☐ Robitussin or other cough syrup as directed ☐ Calamine lotion for bug bites and poison ivy

☐ Sunscreen ☐ Bug repellent

☐ Other (list any other approved over-the-counter drugs):

The Medical volunteer and staff reserve the right to use generic equivalents when available for the name brand over-the-counter medications listed above. I understand that such administration will not always be done under the supervision of medical personnel. I also agree that any first aid treatment may be given as needed. I understand that these over-the-counter medications are not necessarily kept on hand and available to be administered immediately.

Any condition which is associated with fever, significant inflammation, and/or does not respond to the above outlined treatment will be followed-up by a consultation with the student’s parents. Parent/guardian will be contacted if any conditions develop requiring treatment with any of the above over-the-counter medications that are not checked.

I authorize the administration of over-the-counter medications to my child as indicated above. I shall indemnify and hold harmless for any all purposes program staff, Houston Northwest Church, and their members, officers, servants, agents, volunteers, or employees (RELEASEES) against any claims that may arise relating to my child being administered the above indicated over-the-counter medications including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES.

I/We have legal authority to consent to medical treatment for the participant named above, including the administration of medication.

Participant Name Parent/Guardian Name:

Parent/Guardian Signature: Date: