Jr.

High Camp AMPD 2010

August 8-13th
Participant Registration

Camper Name: _____________________________________________ Gender M/F Date of Birth _________________

Home Phone _________________________ School: ______________________________ Grade in fall: _________

Home Address: ________________________________________________ City _________________ Zip _________

Are you in a Home Group: Y/N Home Group leader name: _________________________
Parent/Guardian E-mail _____________________________________ @ ____________________________

Optional Activities
Payment method: cash___ check___ (payable to Rock Church. Memo: camp)
 Paintball $30.00
________$300.00 Full Price (paid in full after July 18, 2010)
 Skate Area$10.00 ________$250.00 Early Bird rate paid in full and received before or on July 18, 2010)
________$200.00 Sibling Rate (rate applies to second sibling. Attach both registration forms)
$_______ Add Optional Activity Amount ($10.00, $30.00, $40.00 both)
$_______ Donate to Partial Scholarship fund ($25, $100, $200 or other)

$_______ TOTAL
____Partial scholarship application: (applications available upon request)

RELEASE, WAIVER, AND INDEMNITY AGREEMENT

For and in consideration of permitting ___________________________________________ (“my child”) to observe, or use any facility or equipment of Shiloah
Springs Bible Retreat, Inc. d/b/a “Indian Hills Camp” (“IHC”), or engage in and/or receive instruction in any activity or activity incidental thereto some of which may
involve danger, risk of bodily injury, or death at Indian Hills Camp, I HEREBY VOLUNTARILY AND ABSOLUTELY RELEASES, DISCHARGES, WAIVE, AND
RELINQUISH ANY AND ALL LOSS OR DAMAGES OR ACTIONS OR CAUSES OF ACTION FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL
DEATH OCCURRING TO MY CHILD AS A RESULT OF MY CHILD'S OBSERVING OR USING FACILITIES OR EQUIPMENT OF INDIAN HILLS CAMP, OR
ENGAGING IN OR RECEIVING INSTRUCTIONS IN ANY ACTIVITIES SOME OF WHICH MAY INVOLVE DANGER, RISK OF BODILY INJURY, OR DEATH OR IN
ACTIVITIES INCIDENTAL THERETO WHEREVER OR HOWEVER THE SAME MAY OCCUR, AND FOR WHATEVER PERIOD SAID ACTIVITIES OR
INSTRUCTIONS MAY CONTINUE. I, AS PARENT OR GUARDIAN OF MY CHILD FOR HIM/HERSELF, HIS/HER HEIRS, EXECUTORS, ADMINISTRATORS, OR
ASSIGNS AGREES THAT IN THE EVENT ANY CLAIM FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH SHALL BE PROSECUTED
AGAINST INDIAN HILLS CAMP OR ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES, THE UNDERSIGNED PARENT OR GUARDIAN WILL INDEMNIFY
AND HOLD HARMLESS INDIAN HILLS CAMP AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM ANY AND ALL CLAIMS OR CAUSES OF
ACTION, INCLUDING ATTORNEY’S FEES, BY MY CHILD OR BY ANY OTHER PERSON OR ENTITY, BY WHOMEVER OR WHEREVER MADE OR
PRESENTED, AND UNDER NO CIRCUMSTANCES WILL I PRESENT ANY CLAIM AGAINST INDIAN HILLS CAMP AND SAID PERSONS FOR PERSONAL
INJURIES, PROPERTY DAMAGE, WRONGFUL DEATH, OR OTHERWISE, CAUSED BY ANY ACT OF NEGLIGENCE BY INDIAN HILLS CAMP AND SAID
PERSONS.
By signing below, I represent that I have read this Release, have requested and have been provided with, or have requested and declined advisement on the
potential dangers/risks of engaging in the observation, activities, or instruction offered, and am fully aware of and understands the terms and the legal consequences
of the signing of this Release. I intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion
of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
In addition to the Release set forth above, as parent/legal guardian of my child I hereby grant permission to the Indian Hills Camp to take photographs of my child
throughout my child’s stay at Indian Hills Camp. I understand that all photographs taken of my child are the sole property of Indian Hills Camp and may be posted on
Indian Hills Camp’s website and promotion and advertising activities of Indian Hills Camp.

Signature of Parent/Guardian:__________________________________ Date: ______________

Printed Name: __________________________________

 Liability and Medical Release form

Participant’s Name______________________________________________________  Male  Female

Home Address: ______________________________________________ City______________ State: _______ Zip _______

Home Phone ________________ Grade in fall: _____

Medical Insurance
Family Heath Insurance Carrier ________________________________ Policy#_____________________________
Doctor ____________________________________________________ Phone (_________) ___________________
Known allergies and reactions: _______________________________________________________________________
Date of last tetanus booster _______/_______ Current Medications___________________________________________
Diet Restrictions _____________________________________ Current Illness/Injury ____________________________
Activity Restrictions __________________________________ Health Related Concerns ______________________
My child may be given over the counter medications (such as Tylenol or Robitussin):  Yes  No
Exception: __________________________________________
Person to notify if Parent/Guardian cannot be reached:

Name ___________________________________ Relationship: ______________ Phone # __________________________

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I, the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in activities in this Shiloah Springs Bible Retreat, Inc. d/b/a “Indian
Hills Camp” (hereinafter "Indian Hills Camp") located at: 15763 Lyons Valley Rd. Jamul, CA 91935, in the County of San Diego.
I hereby authorize the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp, who supervise the activities at Indian Hills Camp into whose care
my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code.
The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the
general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to
any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child.

I further authorize the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp, who supervise the activities at Indian Hills Camp to receive physical
custody of my child, under Section 1283(a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender
physical custody of my child to the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp who supervise the activities at Indian Hills Camp.
It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide
authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician,
dentist, and surgeon, may deem advisable.

Further, I authorize the Rock Church to use photographs and video footage of the participant for promotional materials.

Further, I do certify that the said participant is covered by adequate accident insurance. My consent and signature is given below. I have read and agree to the information give in this
form.

Signature of Parent/Guardian: _________________________________________________ Date: _______________________

Printed Name of Parent/Guardian: _____________________________________________

Parent/Guardian: In the space below please take some time to tell us any area of concern you have for the named
participant: (i.e. social, behavioral, or learning disabilities, etc…) A students experience is our greatest concern. Or
please tell us how can we be praying for this student?
 For Camp Nurse
Medication Check-in Form

Camper’s Name _______________________________________ Gender M/F

Important: All medications must be in the original pharmacy packaging, with appropriate prescription labels. Please do not send medication
that has expired. Hand written instructions by the parent must accompany any medication (prescription or non-prescription). Please write
these instructions on the bottom section of this form.
Important: *If medication is taken at times other than meal times but can be adjusted to meal times for the week, it would be very helpful
for dispensing. For the safety of all campers, all medications, (including non- prescription) must be checked-in with the camp nurse. They will
be stored and dispensed by camp medical personnel (except in cases when personal possession is necessary, e.g. - an inhaler, which needs to
be authorized by the camp nurse).
List all medications brought to camp. Attach additional paper as necessary. Keep medications in original packaging; prescription original
packaging must identify the prescribing physician, medication name, dosage, and frequency of administration.
 My child takes NO routine medications.  My child takes medications as follows:

Med. #1_______________________________ Reason for taking____________________Side effects:_______________________

Time________________________Dosage: ____________________
Note:_______________________________________________________
Med. #2_________________________________ Reason for taking__________________Side effects:_______________________
Time________________________Dosage____________________ Note:_______________________________________________
Med. #3_________________________________ Reason for taking__________________Side effects:_______________________
Time________________________Dosage
Note:_______________________________________________________

Parent Signature ____________________________________ Date ____________________

Phone # ____________________________________________

Date Description Time

 Keep this Page

Packing for Summer Camp

*Limit One Bag per camper in addition to sleeping bag & pillow: Space on bus is limited

BRING TO CAMP

 Sleeping Bag and Pillow (students sleep on one plastic covered mattress on bunk beds)
 Bible (Rock Youth uses the NLT: New Living Translation)
 Pens and notepad
 Daily change of clothes suggested:
o 2 walking shorts
o 1 swim shorts (Note girl swimwear restrictions below)
o 1 long pants
o 5 t-shirts
o Daily change of underwear
o Hoodie or sweatshirt (evenings get chilly)
o Hat or beanie
o Athletic shoes (camp grounds are dirt roads and grass)
 Toiletries (shampoo, toothbrush, deodorant, liquid shower soap, etc.)
 2 Towels: showering and pool
 Shower Shoes – recommended for wearing while in the shower and to walk to the pool
 Modest Swimsuits: one piece swim suit with dark tank top and board shorts for girls. We will play active games in the pool.
 Chap stick and Sun block.
 Water bottle (dehydration is very common at camp)
 Medications sealed and turned in at check in day. (please complete registration form)
 Spending money for camp store. Rock Youth is not responsible for lost or stolen money.
 We suggest only $20.00 maximum for spending money. Keep in a safe place at all times.

DO NOT BRING

 Cell phones (Cell phones will be confiscated and returned on last day of camp)
 Ipod or Mp3 players
 Expensive items including: Jewelry, clothing, toys, electronics, lots of cash, etc…
 Pocket knives, slingshots, or weapons of mass destruction
 Messy foods
 Gum is allowed at camp
 Bad attitudes
 Illegal Drugs, alcohol and or physical violence and threats are considered zero tolerance and camper will be immediate
released to parent/guardian

Other needs: Camp registered nurse & Life Guard for the week.

Questions or concerns: Contact Ryan.lashlee@therocksandiego.org

Call Rock Youth Jr. High Desk #619.764.5190

For updated information: www.therocksandiego.org/ministries/jrhigh/

Drop off: Rock Church Lot E-1 Sunday 8/8: 2:00PM (no early drop offs)

Pick up: Rock Church Main Lobby Friday 8/13: 12:00PM (no later than 1PM please)