Cross Timbers Church

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High School Summer Camp 2022 on Sunday, June 5, 2022 @ 12:00 PM

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EVENT NAME:  CTS HIGH SCHOOL SUMMER CAMP 2022
*Attendee Gender:
*Attendee Date of Birth:
*Attendee Age:
*What grade will the student be in for the upcoming 2022-2023 school year?:
*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.
Parent/Guardian Information
*First Name
*Last Name
*Phone Number
*Email
*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
*Email
*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. 
ALLERGIES/DIETARY RESTRICTIONS
*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

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.
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.

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:
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:
INSURANCE CARD
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.
SIGNATURE
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
*Date
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