Waco Young Life. Freshman Beach Trip Summer 2018

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Aubrie Hensley
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Waco Young Life Freshman Beach Trip Summer 2018 When: June 10th - 13th, 2018 Where: Port Aransas, TX What: One unforgettable trip for the Class of 2018 only!

1 Waco Young Life Freshman Beach Trip Summer 2018 When: June 10th - 13th, 2018 Where: Port Aransas, TX What: One unforgettable trip for the Class of 2018 only!!! You ll have time on the beach, Young Life clubs, good food, and awesome time with your friends and leader. Don t miss out on the only chance you will have for this unforgettable trip! Cost: $ (including deposit). This includes your transportation from Waco and all the food, fun, and activities while in Port Aransas! A non-refundable $50.00 deposit is required with your forms to save your spot. *For financial assistance, please fill out the camp scholarship application and submit with this form How do I sign up... Bring your detached registration and health forms and deposit to club or mail to our office.. and that s it! Spots are limited so sign up today to reserve your spot! Parent Letter (including all trip information and packing list) will be on our website 1 month prior to camp. cut here Please feel free to contact our area office with any questions you may have: 6600 Sanger Ave suite 1a ~ Waco TX ~ (254) ~ YLDavid@me.com Freshman Beach Trip 2018 Registration Form Camper Name Address City State Zip Your phone Parents name Parent phone Parent *all camp communication will be done through .* School Grade Age M / F Circle T-shirt Size: Adult... S M L XL XXL Parent Signature

2 For area use only: Area # CONSENT/ RELEASE FOR YOUNG LIFE ACTIVITY I or my child will be participating in a Young Life activity: Enter description and date of activity here NOTE TO PARTICIPANT/PARENTS-GUARDIANS: Young Life wants you or your child s experience to be a safe and healthy one. However, in the event of an accident or illness, it is important that we have the following information: Name of Participant Birth date Age Sex Last, First, Middle Home Contact Info Parents/Guardian/Spouse Name, Number Home Contact Address Emergency Backup Contact Info (Different from above) Name, Number Any allergies or other medical needs? Limits to activities Name of Physician Physician Phone Medical Insurance Company Policy Number INDEMNITY AND CONTRACT AGREEMENT: I will not hold or attempt to hold Young Life liable for any loss, damage, or injury to person or property caused by any act or neglect of other persons, or caused in any manner other than the willful or negligent act of Young Life, its agents and employees, and will indemnify and hold Young Life harmless from any liability for damages or claims against Young Life arising out of or in any way related to any such loss, damage or injury. I release Young Life, including its trustees, employees and agents, from me or my child s physical injury, including death, or illness while at the activity. I/We will assume the risk associated therewith, whether known or unknown to me/us at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns. Authorization for Treatment: I/We hereby give permission to the medical personnel selected by Young Life to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person. To obtain a copy of Young Life s Notice of Privacy Practices, log on to or call (719) I verify that I or child named above is in good health and capable of participating in strenuous activities and, when necessary, will tailor my/their activities to those within the bounds of my/their physical health. I recognize that any medical treatment that is provided to me (or my child) while attending a Young Life activity will be paid for by my medical insurance company and guarantee payment for services not paid by insurance. Young Life provides SECONDARY insurance for accidents in the amount of $20,000 medical, $4,000 dental. Claims less than $250 are covered in full by Young Life. I hereby grant Young Life permission to use, reproduce, and/or distribute photographs, films, video and sound recordings of me or my child without compensation or approval, for use in materials created for purposes of promoting the activities of Young Life, including the Internet. Signature Date YL1716 (Sept 2010)

3 CAMPING HEALTH, CONSENT AND RELEASE FORM Information in this document is protected by HIPAA privacy laws and should be handled accordingly. This form is only good for travel to and from, and attendance at, this specific camp; it may not be used for any other camping trip. A new form must be completed for each Young Life Camp experience. Note to Parent/Guardian/Guest: Young Life wants the camp experience to be a safe and healthy one. However, in the event of an accident or illness, it is important that we have the following information: 1. Medical history; 2. Medical insurance information; and 3. Proof of physical examination, verified by Physician s signature, required for ALL guests attending Beyond Malibu or camps located in CO or MN (Crooked Creek, Frontier Ranch, RMR, Trail West, Wilderness Ranch, or Castaway). 4. Pregnant and Post-Delivery Teens: Pregnant teens up to 34 weeks and teen moms 6 to 12 weeks post-delivery on camp date must have a physician s release. Teen moms less than 6 weeks post delivery on camp date may not attend. Pregnant teens over 34 weeks to full term are not allowed to attend camp. Pregnant teens over 30 weeks may not attend Washington Family Ranch, Beyond Malibu, Wilderness Ranch, or remote rental camps. Please make a copy for your records. Camps are unable to fax or send copies to other camps. Name Birthdate Sex Age Last First Middle Initial Parent or Guardian (or spouse) Cell Home Address Home Business Address Second Parent or Guardian Emergency Contact Home Address Home Business Address FOR AREA DIRECTORS Area # Area Name Trip Leader/Area Dir. School Name Camp Dates Camper Leader A-Team Summer Staff Work Crew If not available in an emergency, notify: Name Home Address Home ACCIDENT COVERAGE I understand that my personal insurance will be primary coverage for camper accidents and that Young Life s insurance is secondary up to a maximum of $20,000 ($4,000 for dental claims). Exception: if the total claim is less than $250, Young Life will pay the full amount. On claims above $250, Young Life will coordinate payments for deductibles and co-pays. Young Life s policy does not cover camper illnesses. If you have questions, please contact Young Life Benefits and Insurance at (719) My insurance company Policy Number Insurance company address Not currently insured Young Life reserves the right to subrogation if it is later determined that personal medical insurance was in place. PROVIDE Insurance Information Health Care Recommendations: A physician s signature must be on file at time of registration for teens and adults attending Beyond Malibu, or camps located in CO or MN, or a pregnant teen up to 34 weeks or teen giving birth 12 weeks prior to camp (see above). A parent can complete the following health care recommendations if these conditions do not apply. 1.) Does applicant have a medical condition such as sickle cell or respiratory or other ailment or condition which would preclude participation at camps with an altitude of 7 14,000 feet? Yes No 2.) In my opinion, the applicant s condition does does not preclude his/her participation in an active camp program. /Postal 3.) The applicant is authorized to carry an inhaler, epi pen and other emergency medications with them at all times? Yes No Height Weight Blood Pressure I have examined the applicant within the past 12 months. Date examined Licensed Physician s Signature Date Print Name Address Date of form completion *By (*Initial if completed by nurse or physician s assistant) DOCTOR The applicant is under the care of a physician for the following condition(s) Any treatment or medication to be continued at camp (specify dosages) Chronic or recurring illness or medical condition (including behavioral conditions); operations or serious injuries (dates) Explanation of any reported loss of consciousness, convulsion or concussion Any allergies (food, drugs, plants, insects) Any medically-prescribed meal plan or dietary restrictions YL6007 (Apr 2012)

4 Any camp activities from which child should be excluded? (CO and AZ camps have rigorous activities at elevations from 7-14,000 feet.) Name and phone of family physician (if attending camp outside of CO & MN) Name and phone of dentist/orthodontist IMMUNIZATION HISTORY: Required immunizations will be determined locally. Record month and year of basic immunizations. DPT: TD: Diptheria Pertussis (Whooping Cough) Tetanus Tetanus Diptheria HEALTH HISTORY (Give approximate dates) Frequent Ear Infections Chicken Pox Epilepsy Heart Defect/Disease Measles Mononucleosis Diabetes German Measles Convulsions Bleeding/Clotting Disorder Mumps last 60 days Hypertension Hepatitis A Sickle Cell Oral Polio (Sabin) TOPV Currently Pregnant Hepatitis B Injectable Polio (SALK) Has delivered baby Hepatitis C MMR I & II (Measles, Mumps, Rubella) Other in last 12 weeks Allergies/Asthma (Date not needed) Tuberculin test given (most recent) Hay Fever Penicillin Haemophilus influenza b (HIB) Ivy Poisoning, etc. Other Drugs Hepatitis B Insect Stings Asthma Chicken Pox (New York camps only) Other (specify) ALTERNATE TRANSPORTATION ARRANGEMENTS The following people are allowed to pick my child up from camp The following people are NOT allowed to pick my child up from camp Signature of parent/guardian Date AUTHORIZATION FOR TREATMENT This health history is correct to the best of my knowledge, and the person herein named has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulations*; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Young Life to secure or administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named herein. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, and is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgment as to the requirements of such diagnosis or medical, dental or surgical treatment. In addition, I authorize camper to carry emergency medications and use as directed. Signature of parent or guardian or adult camper/staffer Date I agree to remain fully liable and responsible for the payment of any such hospital, doctor, ambulance, dental or medical fees with the exception of the Accident Coverage as set out herein. I further agree that in giving this permission and authorization, Young Life does not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, dental or other medical fees which may be incurred. The completed forms may be photocopied and maintained by authorized personnel for trips out of camp. Signature of parent or guardian or adult camper/staffer Date Camper may carry emergency medications and use as prescribed. Parent/Guardian Date *I have received, reviewed, and agree to the release of my health information as outlined in Young Life s Notice of Privacy Practices handout. Additional copies available at Signature of parent or guardian or adult camper/staffer Date ACKNOWLEDGEMENT OF INHERENT RISK I ACKNOWLEDGE AND UNDERSTAND THERE ARE INHERENT RISKS ASSOCIATED WITH MANY CAMP ACTIVITIES. I WILL ASSUME THE RISK ASSOCIATED THEREWITH, WHETHER KNOWN OR UNKNOWN TO ME AT THIS TIME. I RECOGNIZE THAT MY ATTENDANCE AT A YOUNG LIFE CAMP IS A PRIVILEGE AND AS A CONSIDERATION FOR THIS PRIVILEGE, I RELEASE YOUNG LIFE, INCLUDING ITS EMPLOYEES, AGENTS AND TRUSTEES, FROM RESPONSIBILITY FOR MY ACCIDENTAL PHYSICAL INJURY, INCLUDING DEATH OR ILLNESS, AND LOSS OF PERSONAL PROPERTY WHILE AT CAMP OR DURING YOUNG LIFE SPONSORED TRAVEL TO AND FROM CAMP. THIS RELEASE IS ALSO INTENDED TO INCLUDE ALL CLAIMS MADE BY MY FAMILY, ESTATE, HEIRS, PERSONAL REPRESENTATIVE OR ASSIGNS. I GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL SPECIAL TRIPS OFF THE CAMP PROPERTY WITH PROPER STAFF SUPERVISION. Signature of parent or guardian or adult camper/staffer Date UNDER COLORADO LAW, AN EQUINE PROFESSIONAL IS NOT LIABLE FOR ANY INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO SECTION , COLORADO REVISED STATUTES. UNDER ARIZONA LAW, A SIGNED RELEASE ACKNOWLEDGES THAT THE PERSON IS AWARE OF THE INHERENT RISKS ASSOCIATED WITH EQUINE ACTIVITIES, IS WILLING AND ABLE TO ACCEPT FULL RESPONSIBILITIES FOR HIS OWN SAFETY AND WELFARE AND RELEASES THE EQUINE OWNER OR AGENT FROM LIABILITY UNLESS THE EQUINE OWNER OR AGENT IS GROSSLY NEGLIGENT OR COMMITS WILLFUL, WANTON OR INTENTIONAL ACTS OR OMISSIONS. WAIVER AND RELEASE IF I AM UNDER AGE 18, MY PARENT OR GUARDIAN, BY SIGNING BELOW, ALSO CONSENTS TO MY RELEASE AND HE OR SHE AGREES THAT THIS RELEASE SHALL BE BINDING UPON HIM OR HER AS MY PARENT OR GUARDIAN AS TO ME AND MY ESTATE, HEIRS, PERSONAL REPRESENTATIVES AND ASSIGNS. MY PARENT OR GUARDIAN ALSO PROMISES, BY SIGNING BELOW TO DEFEND, INDEMNIFY AND HOLD YOUNG LIFE HARMLESS FROM ANY CLAIM ASSERTED BY ME AGAINST YOUNG LIFE, INCLUDING ITS TRUSTEES, EMPLOYEES AND AGENTS, IF I SHOULD REPUDIATE THIS RELEASE AFTER OBTAINING ADULTHOOD. PHOTO RELEASE I HEREBY GRANT PERMISSION TO YOUNG LIFE THE RIGHT TO USE, REPRODUCE, AND/OR DISTRIBUTE PHOTOGRAPHS, FILMS, VIDEOTAPES, AND SOUND RECORDINGS OF MY CHILD, WITHOUT COMPENSATION OR APPROVAL RIGHTS, FOR USE IN MATERIALS CREATED FOR PURPOSES OF PROMOTING THE ACTIVITIES OF YOUNG LIFE. Signature of parent or guardian or adult camper/staffer Date I also understand and agree to abide with the restrictions placed on my camp activities as listed herein. Signature of minor or adult camper/staffer Date (If camper is emancipated, proof must be provided prior to camp.) Printed name of minor or adult camper/staffer Date YL6007 (Apr 2012)

5 Waco Young Life Camp Scholarship Form 2018 Camper Information Name: School: Grade: Camp attending: Parent/Guardian Information Name: Mailing Address: Phone Number: Our goal is to provide the funding necessary for each camper from Waco. We understand that there are varying needs of campers in order to help cover their costs for camp. Please keep this in mind and help us by applying for a scholarship amount that best fits the financial NEED that your camper has. We can not guarantee that the scholarship fund will be able to meet the entire need of every camper, and applying for your camper s scholarship need helps us to make sure every camper has the funding needed. You are eligible for a camp scholarship up to 50% of the total of your camp cost. Scholarship amount applying for (up to 50% of total camp cost): $ Camper Tell us why you want to attend Young Life Camp this summer Parent/Guardian Please briefly explain the need for the amount of scholarship funding your camper is applying for Scholarship forms should be submitted by with camp registration and health forms. You will be notified once scholarships begin to be granted in April. Please mail this application to our area Young Life office at: 6600 Sanger Avenue suite 1a; Waco, TX By signing this application, I am committing to attending Young Life camp this summer, and also fulfilling the financial obligation for my camp trip to the best of my ability through my own camp payments, scholarships granted, and/or fundraising projects. Parent/Guardian: Camper: Date:

Town of Dover Recreation Department Day Camp Registration Form

Town of Dover Recreation Department Day Camp Registration Form Name of Camper: Address Age Grade Entering in fall Male/Female Phone # Cell # Date of Birth (Please circle all that apply) Full Day 1. Session