Cross Timbers Church

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Middle School Summer Camp 2021 on Wednesday, July 28, 2021 @ 12:00 PM


We are excited to have ACC join us for camp this year!
*How Did You Hear About Camp?:
*Which student ministry are you apart of:
*Attendee Gender:
*Attendee Date of Birth:
*Attendee Age:
*What grade will the student be in for the upcoming 2021-2022 school year?:
*Attendee School:
*T-Shirt Size:
Roommate requests (list up to three people) *requesting a roommate does not guarantee you will be together, but we will do our best to honor all requests.
*Date of Acknowledgment:
*Parent 1/Legal Guardian First Name:
*Parent 1/Legal Guardian Last Name:
*Parent 1/Legal Guardian Phone Number:
*Parent 1/Legal Guardian Email:
*Parent 2/Legal Guardian First Name:
*Parent 2/Legal Guardian Last Name:
*Parent 2/Legal Guardian Phone Number:
*Parent 2/Legal Guardian Email:
*I am a parent/legal guardian of the above named student/child (herein after referred to as Participant) and hereby give my full permission and consent for my Participant to participate in the Cross Timbers Community Church activity - hereinafter referred to as the “Activity”).  To the best of my knowledge, my Participant is physically fit to engage in the Activity and does not suffer from any illness, disease, injury or handicap which would hamper or impair his/her participation in the Activity, or which may cause illness, disease or injury to others participating in the Activity, or which should otherwise be disclosed for purposes of this document. 
*Having full knowledge and recognizing that the Activity may be dangerous, I hereby waive and release all claims owned by me, my spouse or my Participant and against Cross Timbers Community Church, its employees, agents, representatives, and any and all other persons engaged in or supervising the Activity, including sponsors and parents of other Participants (such persons being collectively referred to herein as the “Church Group”), which claims may arise from my Participant’s participation in the Activity.  I also release and hold the Church Group harmless for any and all loss of or damage to property owned by or relating to my Participant and his/her family, which damage or loss arises from the care and custody of my Participant and/or his/her participation in the Activity.  I agree to indemnify the Church Group for any and all claims, damages or liability resulting from the participation of my Participant in the Activity.  
*In the event my Participant should become ill or injured while participating in the Activity or otherwise under the care, custody or control of Church Group, I direct any adult who shall have care, custody or control over my Participant to contact me if at all possible before authorizing major medical treatment for my Participant.  However, if any adult having care, custody or control over my Participant while he/she participates in the Activity should be unable to contact me, my spouse, or other parent of my Participant, then I specifically authorize such adult(s) to consent to any and all medical treatment which may be deemed necessary or appropriate for the benefit of my Participant, and I specifically authorize the performing or any procedure which such adult(s) deems advisable and at the recommendation of the doctors or other health care providers who are treating my Participant.  I hereby waive and release all claims against any such adult(s) and the Church Group, and agree to hold each harmless of and from any and all claims or liability resulting from such decisions and/or the medical treatment of my Participant.  Adult members have ultimate custody over my Participant while participating in the Activity and all other adult chaperones for the Activity. 
*I understand and agree that if my Participant does not abide by the rules set by the Church Group or others for the Activity, or does not conduct him/herself properly in the sole discretion of the Church Group, he/she will be sent home immediately, at my expense, and he/she will forfeit any remainder of the prepaid expenses for his/her participation in the Activity. 
*This document is signed/agreed to this day and shall be effective until 1 day following the close of the event unless revoked in writing by the undersigned.
*Does the participant have medical insurance coverage?:
*Medical Insurance Policy Holder Name (type NA if none):
*Medical Insurance Company (type NA if none):
*Policy/Subcriber Number (type NA if none):
*Policy Holder's Date of Birth:
*Group or other Identification Number (type NA if none):
*Date Of Last Tetanus Shot:
Please email a copy of the front & back of your medical insurance card to
Please list all known allergies, food or other.  Also describe the severity of the allergy (mild, moderate, severe or anaphylactic).  If anaphylactic, does Participant carry an Epi Pen?
*Please list all allergies and describe the severity of each allergy. (enter NONE, if the participant has no allergies)
MEDICATION LIST INSTRUCTIONSIf student is bringing ANY medications with them to camp. The medication list must be completed and returned before camp.(Medication Form Link)
Return to:
Emergency Contact Information: If the same as Parent / Legal Guardian put N/A.
*Emergency Contact First Name:
*Emergency Contact Last Name:
*Emergency Contact Phone Number:
*Emergency Contact Relationship:
*Cross Timbers Staff, and Serve Team Leaders, May Leave a Voicemail Regarding Medical Information For Above Participant With Emergency Contact #1. 
*Secondary Emergency Contact First Name:
*Secondary Emergency Contact Last Name:
*Secondary Emergency Contact Phone Number:
*Secondary Emergency Contact Relationship:
*Cross Timbers Staff, and Serve Team Leaders, May Leave a Voicemail Regarding Medical Information For Above Participant With Secondary Emergency Contact #2. 
I acknowledge that I am signing this form via electronic means and hereby agree that my electronic signature shall be as binding on me as though I had originally signed the same in my own handwriting.
*Parent/Legal Guardian
First and Last Name