Special Ministries Camp at WHR Wild Wild West Camper Packet

Transcription

1 Special Ministries Camp at WHR Wild Wild West Camper Packet Fill out, sign and return ALL information sheets (keep this front page). Camp Dates: September 19-21, 2014 Registration Due: Friday, September 5 Cost: Check In: Drop Off: Questions: $ (checks to SBC/memo camper s name) If mailing: SBC/Special Ministries 7601 E Shea Blvd, Scottsdale, AZ Send forms ASAP turn in monies by September 15 12pm - 12:30pm Friday, September 19 Special Ministries Adult Room Scottsdale Bible Special Ministries South Parking Lot on Shea Amy Daniels Office phone: Amy adaniels@sbcaz.org Bus Returns: 3:30pm Sunday, September 21 Pick Up: Scottsdale Bible South Parking Lot off Miller Rd

2 PACKING LIST AND EQUIPMENT *Please put camper s name on ALL luggage and personal items Pillow Blanket two just in case (sleeping bag may be too hot) Sheets (twin set) Bath towel Wash cloth Shampoo/conditioner Soap Toiletries Closed toe shoes closed toe shoes are required on the property Socks and undergarments Jeans or long pants Shirts (both short sleeves and long sleeves) Shorts (knee length) Pajamas Jacket (chilly at night) Extra underwear or pull-ups (just in case) Cowboy Boots (if you have them) Sun screen lotion (up to you) Bug repellant (if you want) Sunglasses and/or hat (not a must) Flashlight (not a must, but very important to most campers) Rain jacket (just in case) Please, pack sleeping bag or sheets and pillows in a bag to keep clean and labeled with camper s name. IMPORTANT: Prescription medications must be in prescription bottles with doctor s instructions (even vitamins will be given to the nurse). Place in a plastic baggie with first and last name on bag. Give directly to the volunteer nurse before boarding the bus. Campers who are not feeling well should not be sent to camp. Whispering Hope Ranch Emergency Contact Numbers for Parents/Caregivers Main Ranch Office (M-F 9:00 a.m. 4:00 p.m.) Wellness Center Phone & Answering Machine KEEP THIS PAGE THE WKND OF CAMP FOR PICK UP INFO & NUMBERS

3 Registration form for Special Ministries Fall Camp 2014 Register by September 5th: Scottsdale Bible Church Special Ministries 7601 E. Shea Blvd. Scottsdale, AZ CAMPER: First (what you go by) Last [] Male [] Female Age: DOB: T-Shirt Size: S M L XL XXL XXXL (circle one) Address City St Zip Parent/Caregiver: First Last Parent/Caregiver Cell Phone: Home Phone: MEDICAL HISTORY* Describe medical conditions: [ ] Yes [ ] No Please give detailed information how to best care for camper: Does the camper take any medications? [ ] Yes* [ ] No *Please, fill out MEDICATION and DOSES for nurse on pages 3 &4 à ONLY PRESCRIPTION MEDS & NECESSARY OVER THE COUNTER IN ORIGINAL BOTTLES NO VITAMINS OR SUPPLEMENTS due to space for so many students meds & needing meds at the same time EMERGENCY CONTACT Name of person to contact in case of Emergency if we can t get a hold of you: Name Relation Cell Phone ( )

4 Are there other things that you would like us to know? We will better care for your student with any and all information you share: Include bathroom needs, night time issues, seizures and precautions. Please, alert us of any food allergies and/or restrictions regarding food. Special Ministries staff, volunteers and nurse will do everything possible to keep your child/student safe and healthy this weekend. The better informed we are and the supplies and medications you send will prepare us for an amazing trip! Keep us in your prayers!

5 Scottsdale Bible Church Special Ministries 2014 Medical Release for ALL campers This form is filled out for our Camp Nurse and their Buddy CAMPER S NAME PHONE NUMBER BIRTHDATE Sex: M F GROUP HOME or SCHOOL GRADE PARENTS or CAREGIVERS NAMES CELL PHONE Is camper covered by family medical insurance? YES NO IF YES, MEDICAL INSURANCE NAME DOCTOR EMERGENCY CONTACT PHONE PHONE PHONE Date of last tetanus shot Please list any medical conditions, recent illness or surgery: HEALTH HISTORY MEDICAL RELEASE If your child should require medical attention at camp for injuries or illness contracted prior to coming to camp, please send us the information necessary to give him/her proper medical service during his/her stay at camp. In the event of a medical emergency in which my child is in need of immediate hospitalization, medical attention, or surgery, and after reasonable unsuccessful efforts have been made to contact me or my spouse, consent for the emergency attention may be given by any person standing to loco parents to my child pursuant to A.R.S Parent s Signature Date Insurance Company Name of Insured Policy Number

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7 PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS Scottsdale Bible Church - Special Ministries 2014 I hereby give the SBC camp volunteer registered nurse permission to administer the following products according to manufacturer s instructions or as otherwise specified. I trust the volunteer registered nurse to use his/her best judgment as situations arise. If there is any doubt, he/she can call for verification. Food allergies will be listed below. Please check YES or NO for the medications listed blow. YES NO Specify if desired: q q Ibuprofen q q Insect repellant q q Cold Medicine q q Rash ointment q q Tylenol q q Antiseptic ointment q q Band-aids q q Anti-itch cream q q Hydrogen peroxide q q Cough syrup q q Cough drops q q Decongestant q q Antihistamine q q Ipecac syrup q q Pepto Bismol q q Other q q Other q q Other Camper s Name (please print): Parent/Caregiver Signature: Phone numbers: (Cell) MEDICATION AND DOSES LIST ALL medications MUST be sent in original prescription bottles & OTC bottles. **FILL OUT A FORM FOR EVERY MEDICATION INCLUDING OVER THE COUNTER MEDS Do not send vitamins and supplements due to space for students meds & distribution time INSTRUCTIONS: _ Continues on Back

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9 WHISPERING HOPE RANCH FOUNDATION LIABILITY RELEASE AND INDEMNIFICATION AGREEMENT (PARENT / GUARDIAN / CHILD / WARD) Read both sides carefully before signing: Your legal rights and those of your child or ward will be affected by this agreement. The following signed release is required of all adults and minors before being granted access to Whispering Hope Ranch. A parent/guardian must sign the release for participants under the age of 18 or under legal guardianship. 1. PARTIES: Whispering Hope Ranch Foundation ( WHRF ) owns camp facilities at Whispering Hope Ranch ( WHR ), outside Payson, Arizona. I am enrolling my minor child(ren) or ward(s) (together Child ) in a camp/retreat at WHR that is organized by a sponsoring organization (the Sponsor ) and is for recreational and educational purposes. All activities associated with the camp/retreat, whether occurring at WHR or elsewhere, are referred to in this Agreement as the Camp. I hereby request, on behalf of myself and my Child, access to the Camp. In consideration of, and as a condition to, WHRF s granting me and my Child access to the Camp, I as an individual and on behalf of my Child, understand and agree as follows (the Agreement ): 2. RISKS OF CAMP ACTIVITIES: (a) While at the Camp, I and/or my Child will be in a wilderness setting and may participate in activities, including horseback riding, interacting with domesticated animals, field sports, court sports, nature activities, hiking, and other activities that present a risk of personal injury or other harm. Some of the Camp activities, such as horseback riding and hiking, may take place on property outside of WHR. The Camp includes rough terrain and open creeks and other bodies of water. Non-domesticated animals may be present at the Camp or in areas where Camp activities take place. As a consequence, I and/or my Child may be exposed to dangers and hazards and may suffer injuries, including the inherent risks associated with equine activities, falls, fractures, concussions, drowning, overexertion, overheating, and injuries caused by dangerous weather, lack of fitness or conditioning, wildlife, behavior of other campers, disease, exposure, equipment failures, and negligence by others. (b) Some Camp activities may be sponsored, led or directed by the Sponsor and not by WHRF. I understand that WHRF has no control over the safety or suitability of any Camp activities sponsored, led or directed by the Sponsor and shall not be liable, or in any way responsible, for the suitability or safety of any such Camp activities. (c) As a consequence of the foregoing risks, I and/or my Child may be seriously hurt, including the potential for injury or death, from the resulting injuries, and my property or the property of my Child may also be damaged or destroyed. (d) Some Camp activities may occur at locations that are remote from hospital facilities and qualified medical care, and emergency medical evacuation may be required. I understand that I am responsible for any medical care and/or evacuation costs for my Child or me. (e) I understand that WHRF does not provide on-site medical staff or medical care and that WHRF is not responsible for any medical care that may be necessary for me or my Child during the Camp. 3. ASSUMPTION OF THE RISKS: For myself and/or on behalf of my Child, I hereby freely assume the abovementioned risks and the risk of any harm, injury or loss that may occur to me or to my Child, or to our property, during the Camp including any risks caused by the negligence of WHRF, its officers, directors, employees, volunteers or contractors and am willing to accept full responsibility for my safety and welfare and/or the welfare and safety of my Child. 4. RELEASE OF LIABILITY: For myself and on behalf of my Child, I RELEASE Whispering Hope Ranch Foundation, and its officers, directors, employees, volunteers, and contractors ( the Released Parties ) FROM ALL LIABILITIES, CAUSES OF ACTION, CLAIMS AND DEMANDS arising out of or relating to, in whole or in part, participation in the Camp, including, without limitation, any injury, death, loss or harm that occurs to me or to my Child or to our property during or as a result of the Camp. This release includes claims for the negligence of the Released Parties and claims for strict liability for abnormally dangerous activities. This release does not extend to claims for gross negligence or for intentional misconduct or to any other liabilities that Arizona law does not permit to be excluded by agreement. 5. COVENANT NOT TO SUE: For myself and/or on behalf of my Child, I agree NOT TO SUE or make a claim against the Released Parties for death, injuries, loss or harm that are released in Section 4 of this Agreement Final Exhibit 5 WHR Liability Release (minors) Page 1 of 2 Initial (Parent/Guardian)

10 6. INDEMNIFICATION, HOLD HARMLESS, AND DEFENSE: I promise to INDEMNIFY, HOLD HARMLESS, AND DEFEND the Released Parties (defined in Section 4) from and against any and all claims described in Section 4 of this Agreement, including claims for their own negligence. I also promise to INDEMNIFY, HOLD HARMLESS, AND DEFEND the Released Parties from and against any and all claims for or arising out of my negligence, and/or my Child s negligence, and from and against any other claim arising from my conduct and/or my Child s conduct during the Camp. I will reimburse the Released Parties for any damages, reasonable settlements and defense costs, including attorney s fees, that they incur because of any such claims made against them. 7. SEVERABILITY: I agree that the foregoing release of liability, covenant not to sue, and indemnity are intended to be as broad and inclusive as is permitted by Arizona law. I agree that if any portion or provision of this Agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law. 8. APPLICABLE LAW & FORUM: This Agreement is governed by and shall be construed in accordance with the laws of the state of Arizona, without any reference to its choice of law rules. Any dispute arising from this Agreement or in any way associated with the Camp shall be brought only in the Superior Court of Maricopa County, Arizona, and I agree to the jurisdiction and venue of that court for any such dispute. I have fully informed myself of the contents of this Agreement by taking the necessary time to read it before signing it. I have had the opportunity to ask questions of WHRF about the terms of the Agreement. I UNDERSTAND THAT THIS AGREEMENT AFFECTS AND WAIVES MY LEGAL RIGHTS AND THE LEGAL RIGHTS OF MY CHILD, and I agree, on my behalf and on behalf of my Child, to be bound by all of its terms. No oral representations, statements or other inducements to sign this Agreement have been made apart from what is contained in this document. All Camp Attendees (including parents/guardians) must be listed below. Parent/guardian must sign on behalf of self and minor children/wards. Camp Attendees Please print full name. Please check correct box: 1. Child/Ward Parent/Guardian 2. Child/Ward Parent/Guardian 3. Child/Ward Parent/Guardian 4. Child/Ward Parent/Guardian Signature (Parent/Guardian): Date: Printed Name (Parent/Guardian): Signature (Parent/Guardian): Date: Printed Name (Parent/Guardian): Page 2 of 2 Initial (Parent/Guardian)

11 Sponsor Organization or Camp Name: WHISPERING HOPE RANCH FOUNDATION PHOTOGRAPHY RELEASE I consent to and authorize the use and reproduction by Whispering Hope Ranch Foundation ( WHRF ) of any and all photographs and any other audio-and/or video recordings of the voices and images taken of me and/or my child(ren)/ward(s) for promotional material, educational activities, use on WHRF s website, exhibitions or for any other use for the benefit of WHRF. I hereby waive any claim for payment or other compensation for any such use by WHRF of my and/or my child s(ren s)/ward s photographs and/or any other audio and/or video recordings. I DO NOT CONSENT TO THE PHOTOGRAPHY RELEASE. I HAVE CAREFULLY READ THE ABOVE RELEASE AND SIGN IT WITH FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE. All Camp Attendees (including parents/guardians / staff / volunteers) must be listed below. Parent/guardian must sign on behalf of self and minor children/wards Camp Attendees Please print full name. Please check correct box Child/Ward Parent/Guardian Staff/Volunteer Child/Ward Parent/Guardian Staff/Volunteer Child/Ward Parent/Guardian Staff/Volunteer Child/Ward Parent/Guardian Staff/Volunteer Signature (Self/Parent/Guardian/Staff/Volunteer): Date: Printed Name (Self/Parent/Guardian/Staff/Volunteer): LEGAL FINAL Exhibit 6_Photography Release All Participants