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Middle School Summer Camp 2022 on Wednesday, June 29, 2022 @ 12:00 PM
Attendee's First Name:
Attendee's Last Name:
Attendee's Email Address:
Attendee's Phone Number:
Antigua and Barbuda
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
British Virgin Islands
Central African Republic
China, Hong Kong Special Administrative Region
China, Macao Special Administrative Region
Cocos (Keeling) Islands
Democratic People's Republic of Korea
Democratic Republic of the Congo
Falkland Islands (Malvinas)
French Southern Territories
Heard Island and McDonald Islands
Iran (Islamic Republic of)
Isle of Man
Lao People's Democratic Republic
Micronesia (Federated States of)
Northern Mariana Islands
Papua New Guinea
Republic of Korea
Republic of Moldova
Saint Kitts and Nevis
Saint Martin (French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Sint Maarten (Dutch part)
South Georgia and the South Sandwich Islands
State of Palestine
Svalbard and Jan Mayen Islands
Syrian Arab Republic
The former Yugoslav Republic of Macedonia
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United Republic of Tanzania
United States Minor Outlying Islands
United States Virgin Islands
United States of America
Venezuela (Bolivarian Republic of)
Wallis and Futuna Islands
Address Line 1:
Address Line 2:
City, State Zip:
EVENT NAME: CTS MIDDLE SCHOOL SUMMER CAMP 2022
-- Select --
Attendee Date of Birth:
What grade will the student be in for the upcoming 2022-2023 school year?:
-- Select --
-- Select --
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.
Cross Timbers staff, and serve team leaders, may leave a voicemail regarding medical information for above participant with the above listed Parent/Guardian.
(other than parent listed above)
Relationship to Participant
Cross Timbers staff, and serve team leaders, may leave a voicemail regarding medical information for above participant with the above listed emergency contact.
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 any dietary restrictions the participant has. (type NA if none)
Does the participant have an inhaler prescribed to them?
MEDICATION LIST INSTRUCTIONS
bring ANY over the counter medications other than allergy medication. The medications that are listed below are the medications the nurse will have on hand and able to give your child if selected.
All allergy medications
be listed in the prescription section and handed over to the nurse at check-in.
medications your child is
to take while at camp.
My child CAN NOT take any of the above listed medications
PRESCRIPTION MEDICATION LIST & INSTRUCTIONS
Please complete this form for all medication(s) that your child will be taking over the
course of this event, including over-the-counter allergy medications, inhalers, or any medication that you will be sending with your child. Please read the following Medication Policy. Your signature below indicates
that all information provided on this form is correct and that you understand the Medication Policy.
All medications, both over-the-counter allergy and prescription medication, must be submitted to the Nurse at event check-in with the exception of Epi-Pens, inhalers, and diabetic supplies.
All prescription medication must be in the ORIGINAL CONTAINER.
Over-the-counter allergy medications must have the participant's name clearly written on the original container.
MEDICATION DISMISSAL POLICY
There will be no exceptions to this policy.
Please select one of the following statements:
Please release any remaining medication to my child at the conclusion of the event.
Please DO NOT release medication to my child at event dismissal. I will pick up medication at event dismissal.
Any medications not picked up at that time will be destroyed.
Please list all medications with the name of medication listed on the bottle as well as the dosage and instructions.
Date Of Last Tetanus Shot:
A copy of the front & back of your medical insurance card MUST be uploaded & submitted by 6/22/2022.
Does the participant have medical insurance coverage?:
Medical Insurance Policy Holder Name (type NA if none):
Medical Insurance Policy Holder Email (type NA if none):
RELEASE, INDEMNITY AND CONSENT TO MEDICAL TREATMENT – PARTICIPANT
Date of Acknowledgment:
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.
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.
First and Last Name
Walk on Water
Agreement to Participation
Assumption of Risk and Release of Liability
PLEASE READ BEFORE SIGNING
The undersigned acknowledges that during the session that the applicant has requested to participate in, Certain risks and danger may occur. The undersigned recognizes that such risks and danger may include Loss or damage to personal property, physical or psychological damage and/or injury, not excluding fatality due to accident. I certify that I am completely healthy (both physically and emotionally) and capable of participating in this session. I have listed on the medical information form medical conditions That WALK ON WATER Inc. should be aware of which may hinder my participation in the session. However, I understand that it is solely my responsibility to determine whether there is any medical reason That I should not participate in the session and to obtain approval for any and all activities from the appropriate Health-care providers. The health history is correct as far as I know, and the person herein described has permission To engage in all prescribed camp activities except as noted. I hereby authorize the medical personnel selected by The camp director and/or church leader to order x-rays, routine tests, treatment, and necessary transportation for Me/my child as deemed necessary.
I, individually and on behalf of the minor and all other family members, Executors or administrators, do hereby release, forever discharge, and agree to hold blameless WALK ON WATER Inc. and its counselors, staff, employees, agents, and lessors from any and all liability, claims, INCLUDING, BUT NOT LIMITED TO THE NEGLIGENCE OF WALK ON WATER Inc. STAFF, DIRECTORS, COUNSELORS, EMPLOYEES, AGENTS and LESSORS, or demands for personal injury, sickness, or death, as well as property Damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant While said person is participating at WALK ON WATER. In consideration of, and as part payment for, the Right to participate in such a program and the services arranged for me by WALK ON WATER Inc. its staff, Directors, counselors, employees, agents and lessors, from any and all liability, actions, causes of action, INCLUDING BUT NOT LIMITED TO THE NEGLIGENCE OF WALK ON WATER INC DIRECTORS, COUNSELORS, EMPLOYEES, AGENTS and LESSORS, debts, claims, and demands of every kind and nature Whatsoever, whether for bodily injury, property damage or loss otherwise, which I now have or which may arise From or in connection with my program or participation in any other activities arranged for me by WALK ON WATER Inc. its staff, directors, counselors, employees, agents, and lessors, for all members of my family, Including any minors accompanying me.
I SPECIFICALLY AGREE THAT MY AGREEMENT TO INDEMNIFY AND HOLD HARMLESS WALK ON WATER INC. ITS STAFF, DIRECTORS, COUNSELORS, EMPLOYEES, AGENTS and LESSORS, INCLUDES ALL LITIGATION COSTS AND ATTORNEY FEES FOR ANY LITIGATION BROUGHT ON BY MYSELF, ON BEHALF OF THE MINOR, IF APPLICABLE, OR ANY OTHER FAMILY MEMBER.
I grant permission to WALK ON WATER to use photographs and any video taken by WALK ON WATER for use on web sites or other electronic form or media, without notifying me. I hereby waive any right to inspect or approve the photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photographs. I hereby agree to release and hold harmless WALK ON WATER, via electronic or media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any re-use, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in production of the finished product.
I also state that I am not under, and will not be under the influence of any Chemical substance including alcohol. I fully understand that my physical activity involves risks of injury. I also understand that my participation in this WALK ON WATER Inc. program is entirely VOLUNTARY. I enter into this session and take full responsibility for my decision to participate or not to participate and agree To follow all safety instructions.
Name of Participant
Signature of Participant (If under 18, parent or guardian must sign)
Signature of Witness