Cross Timbers Church

Event Registration

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Middle School Summer Camp 2022 on Wednesday, June 29, 2022 @ 12:00 PM

*Attendee Gender:
*Attendee Date of Birth:
*Attendee Age:
*What grade will the student be in for the upcoming 2022-2023 school year?:
*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.
Parent/Guardian Information
*First Name
*Last Name
*Phone Number
*Cross Timbers staff, and serve team leaders, may leave a voicemail regarding medical information for above participant with the above listed Parent/Guardian. 
*Emergency Contact (other than parent listed above)

First Name
*Last Name
*Phone Number
*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?

Students can NOT 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 MUST be listed in the prescription section and handed over to the nurse at check-in.
Select all medications your child is APPROVED to take while at camp.

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. 

There will be no exceptions to this policy. 
*Please select one of the following statements:
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):
*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.
*Parent/Legal Guardian
First and Last Name
Walk on Water
Agreement to Participation
Assumption of Risk and Release of Liability
*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 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