AGAPE VILLAGE SUMMER READING AND PERFORMING ARTS CAMP
(AVSRPAC)
2018 SUMMER CAMP REGISTRATION FORM
NAME _____________________________________________ AGE _____________________ CAMPER’S NAME _____________________________________________ AGE _____________________ CAMPER’S NAME _____________________________________________ AGE _____________________
Parent’s Name: _______________________________________________________________________ Address: _____________________________________________________________________________ City: ________________________________________ State: ___________ Zip: ____________________ Home Phone _____________________________ Work Phone: _________________________________ Cell Phone: ______________________________ Email Address__________________________ Registration Date: ________________________
The camp hours are 9 am to 3pm, Monday through Friday July 9th through July 20th with a performance on the 21st @ 2pm. The camp will be held at Oak Pointe Commuity Center. 730 E. Boudary St. Augusta GA 30901.
TERMS OF ENROLLMENT/LIABILITY WAIVER:
AGAPE VILLAGE SUMMER READING AND PERFORMING ARTS CAMP is not responsible for camper’s personal belongings if lost, stolen or damaged.
AVSRPAC will make every effort to provide proper Supervision so that losses will be at a minimum.
Directors reserve the right to deny, cancel, sever, or suspend a child’s enrollment if deemed in the best interest of the camper or AVSRPAC.
I realize every precaution is taken to eliminate any injuries or hazards, and a competent supervisor is present; however, in the event of an injury, I hereby waive, release and hold harmless from any liability for damages for personal injury including accidental death, as well as from claims for property damage which may arise in connection with the above named activity, against the director, ISRAPAC, its officers, agents, employees, and volunteers.
In case of an accident or other emergency, personnel of ISRAPAC and/or its agents are hereby authorized to secure medical care if deemed necessary as a result of accident or injury of participant. I further agree to pay any and all costs incurred as a result of said treatment.
PARENT/GUARDIAN SIGNATURE: __________________________________________________________ DATE ______________________
Important Information Form
Child’s Name: ________________________________________ Age: ________ Sex: _____ D.O.B.:________________
Parent or Guardian Name: ___________________________________________________________________________
Phone Contact: Home/Cell: _____________________________________________________
Work: __________________________ Email Address: ___________________________
In Case of Emergency:
Emergency Contact: ___________________________________________________________________ Number: ________________________
Alternate Contact: _____________________________________________________________________ Number: ________________________
Preferred health care facility: _____________________________________________________________________________________ (Nearest one if none preferred)
Family Doctor: _________________________________________________________________________ Number: ________________________ (Physician on staff if none entered) GENERAL HEALTH INFORMATION: Please list any and all medical conditions: _____________________________________________________________________________________ _____________________________________________________________________________________
Recent Medical Attention or Serious Injuries: _____________________________________________________________________________________ _____________________________________________________________________________________
RECOMMENDATIONS & RESTRICTIONS WHILE AT CAMP:
Restricted activities or physical limitations of camper: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Other Health-related information: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ If medication is to be administered at camp, please fill out Medical Form included. Behavioral or emotional information: _____________________________________________________________________________________ _____________________________________________________________________________________ Seasonal Allergies & Treatment: _____________________________________________________________________________________ _____________________________________________________________________________________Food Allergies & Treatment: _____________________________________________________________________________________ _____________________________________________________________________________________
HEALTH HISTORY STATEMENT
This health history is correct to the best of my knowledge, and the camper listed above has permission to engage in all camp activities without limitations except as noted.
EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp director to secure proper treatment for the person named above.
USE OF PHOTOGRAPHS RELEASE STATEMENT
I authorize ______________________________________________________ camp to use photographs of my child in their advertising material. Yes / No
AUTHORIZATION FOR PICKUP
The following persons are authorized to pick up my child or children: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Signature: _________________________________________ Date: ___________________________
CAMPER MEDICAL FORM
CAMPER’S NAME________________________________________________________________
I authorize AVSRPAC staff to administer the medication listed below as prescribed by my physician.
Parent/Guardian Name _____________________________________________________________ Parent/Guardian Signature __________________________________________________________ Name of Medication to be administered: _______________________________________________
List the condition for which the medication is being used and any cautionary information specific to the medication: _____________________________________________________________________________________ _____________________________________________________________________________________ The instructions for administration, including the dosage and frequency of administration: _____________________________________________________________________________________ _____________________________________________________________________________________ List date, time and name of the person administering the medication to the camper: _____________________________________________________________________________________ _____________________________________________________________________________________ List any medication errors and any adverse drug reactions: _____________________________________________________________________________________ _____________________________________________________________________________________ The camp director shall inform the prescribing physician of any medication error or adverse drug reaction. The camp director shall return any unused medication to the camper’s parent or guardian within three working days after the camper’s last day. The camp director shall destroy any medication he or she is unable to return.
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