SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016

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1 SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016 Student s Name: Grade Entering: Date of Birth: / / Gender Male Female Address: City, State, Zip: Home Phone ( ) Parent s Name(s): *Parent s Parent s Address (if different): City, State, Zip: Lives with: Father Mother Both Parents Others Mother s Work phone:( ) Mother s Cell Phone:( ) Father s Work phone:( ) Father s Cell Phone: ( ) Emergency Contact Name & Relationship: Emergency Contact Phone:( ) Church Name: City: Please list any specific persons who are NOT authorized to pickup your child: T-Shirt Size We are giving free t-shirts to individuals registered 1 month prior to their week of camp *You will receive registration confirmation by . Office Use Only Pay. Date: Amount: Check: Credit: Check #: Church Paid: Church Amt. Camp Scholarship: PLEASE CHOOSE WEEK WEEK Date Grade Entering Dean **Early Fee Regular Fee Beginner June Alex Henderson $45 $45 Junior June Alex Henderson $150 $155 Intermediate June 26-July Kenny Shubert $185 $200 Jr. High June Pam Oaks $185 $200 High school July Doug OB Roberts $185 $200 Adventure Weeks Intermediate June David Lewis $210 $250 Jr. High July John Pryor $210 $250 High School July John Pryor $275 $365 Yellowstone N.P. July Jeff Beckham $450 **Early Fee refers to 2 weeks before the camp week. EXTRA $50 FEE TO REGISTER DAY OF CAMP. ADDITIONAL DISCOUNTS Registering by May 1 - $10 First Time Camper $25 (doesn t apply to beginner) Bring a friend who is 1st time camper $25 (Doesn t apply to Beginner Week) TUTION Week Price Discounts Church Scholarships Church name: Total Please make check payable to Smoky Mountain Christian Camp (SMCC) P.O. Box 116 Coker Creek, TN METHOD OF PAYMENT (circle one) Visa MC Discover Check Cash - Check # Credit Card # Expiration Date:

2 SWIMMING INFORMATION My child knows how to swim Not At All Some Pretty Well Great My child has my permission to swim at camp and on outings. Signature of Parent/Guardian: Date: / / Risk of Injury Waiver of Liability I give my permission for my child to participate in recreation, swimming, and learning activities, and to be bound by all camp policies in force. Initial I desire that my child participate in the full range of camp activities and acknowledge the natural condition of the camp and the interactions with other children of various ages may subject my child to risk of injury on and off the camp premises. Initial I therefore release the camp from any responsibility other than normal supervision and care. In case of accident, I will not hold Smoky Mt. Christian Camp, its staff, management, faculty, volunteers, or officers liable. Further I waive any and all claims or causes of action against the foregoing parties which may arise as a result of an accident or an injury to my child at Smoky Mountain Christian Camp. Initial 4. In case of emergency, I hereby give permission to the physician selected by the camp management or dean to secure proper treatment for my child as named on this form. Doctor calls, treatment or hospitalization are to be charged to our family insurance. Initial 5. I understand that Smoky Mountain Christian Camp and its staff should not be held responsible for any articles lost, stolen, or left at camp. Initial 6. I give my permission to leave camp grounds for various service or fun related activities under the supervision of an adult faculty member. I will not hold Smoky Mt. Christian Camp responsible for any injuries that may occur while away from the camp. Initial 7. By registering my child in the programs of Smoky Mountain Christian Camp, I give my consent for the camp to use my child s photograph in camp promotion and publicity. Initial Signature: Date: / / IMPORTANT INFORMATION Office Phone (423) Fax Phone (423) Camper Phone (423) (Dining Hall) Web Site:

3 Smoky Mountain Christian Camp Authorization for Medical Treatment for Minors I/We,, give Smoky Mountain Christian Camp permission to provide and/or secure medical care for from / / through / /. The child named above is allergic to the following: The child named above regularly takes the following medications: I/We authorize SMCC to deal with minor issues as follows: Minor Cuts & Bruises (using Antiseptic, Neosporin or Equivalent, Band-Aids, etc.) Headaches Preferred Medicines: Minor Gastrointestinal Issues (Stomach Aches, Diarrhea, etc.) Preferred Medicines: Administering the following prescription medication (which I have provided in the the original packaging with my child s physician s approval: I/We understand that this document and the attached medical details form shall be kept on file for reference at SMCC and would only be presented to a physician, dentist or appropriate hospital representative if immediate medical, dental, surgical care or hospitalization should be required for any reason. With my signature below, I certify this limited authorization and my approval of the stated guidelines above. Signature of Father or Male Guardian Printed Name of Father or Male Guardian Signature of Mother or Female Guardian Printed Name of Mother or Female Guardian Date Signed: / / Date Signed: / /

4 Smoky Mountain Christian Camp Health History and Medical Examination Form for Minors The more complete information you provide, the better we are able to work with your child to ensure he/she receives any care needed. At your discretion, you may leave some details blank. Please type or write clearly and legibly. Name of Minor: (Last, First, Middle Initial) Date of Birth: (XX/XX/XXXX) Address: City: St: Zip: Parent or Guardian and Social Security Number: Phone: Alternate Phone: Parent or Guardian and Social Security Number: Phone: Alternate Phone: Emergency Contact Information (parent/guardian): Emergency Contact: Phone: Relationship: Alternate Phone: Health Insurance Information Policy Holder's Name: Insurance Company Name: Insurance Company Address: Policy Number: Group Number: Insurance Company Phone: Check all that apply: Diabetes Sleep disturbances Heart Defects/Disease Fainting Asthma Bed wetting Ear Infections Constipation Musculoskeletal Disorders Chicken Pox Convulsions/Epilepsy/Seizures Measles Sinusitis (Sinus Infections) German Measles Physical Restrictions Mumps Kidney/bladder illness Rheumatic Fever Mental/psychological disorder Tuberculosis Hypertension Kidney Disease Arthritis Eating Disorders (Anorexia, Bulimia, etc.) Nosebleeds Headaches/Migraines Has begun menstruation Surgery/Hospitalization in the last 5 years Menstrual cramps Currently under doctor s care (details below) Bleeding disorder Emotional Separation Anxiety Other: Please list any previous surgeries and after completing the last page, please add any addition details you want to add here.

5 Camper Name: Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to medications, food, bees, animals, plants, etc. Allergies Reaction/ Severity Treatment Date of last Reaction Does your child suffer from Anaphylaxis? Yes No *Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Does your child carry an Epipen? Yes No Does your child carry an inhaler? Yes No Medical Conditions (including any precautions or restrictions on activities) Name of Condition Effects Medications: List any medications he/she is currently taking (or has taken in the recent past) including dosage schedule and specific instructions for use. Also, please note that all medications must be turned into the nurse at the beginning of the week in its original prescription container Medication Purpose Dosage Schedule Specific Instructions Does your child have a Special Medical or Dietary Regiment to be followed? If so, please explain: Yes No Has your child had any adverse reactions to general anesthetics? Yes No If so, please explain: Any other information not covered in this form that is important that advisors know for this trip:

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