Registration Form
Child's Name:_______________________________________________
Parent/Guardian Name:____________________________________________________
Address:__________________________________________________
City Street Zip:______________________________________________
City Street Zip:______________________________________________
Phone:___________________________________________________
Emergency Contact:__________________________________________
Emergency Phone:___________________________________________
***************************************************
My Child will Attend Camp on these dates:______________________________________________
Amount Paid (circle one): $50 $200 $275
(Balance due 30 days prior to camp)
***************************************************
Health history:
Child’s Name:___________________________________
Grade: _____Date of Birth:_______________
We ask that you administer any medication to your child at home before or after camp. If necessary please complete a line for each medication sent with the child to camp. All medication must be in original containers with the prescription instructions from your child’s pediatrician, in your child’s name. It must be checked in with a member of the "Peace & Carrots Camp"/Oakleaf Mennonite Farm staff upon arrival.
I hereby request and authorize the Oakleaf Mennonite Farm staff, to give the following medication(s) to my child:
Currently taking any medication? Yes or No If yes, what?
NAME OF MEDICATION DOSAGE FREQUENCY WHAT IT’S FOR?
______________________________________________________
______________________________________________________
______________________________________________________
List Allergies (Food, drugs, etc...)
______________________________________________________
______________________________________________________
______________________________________________________
Medical Conditions (Diabetes, Epilepsy, Asthma, Fainting, Heart Condition etc…)
______________________________________________________
______________________________________________________
______________________________________________________
Are the student’s immunizations up to date? Yes or No
Does your child dehydrate easily? Yes or No
Can your child take part in athletic activities including jumping, running, swimming, and water sports?
Yes or No
If No please list:
______________________________________________________
As the parent (or legal guardian) of __________________________________, I certify that I have been
informed that, as a participant in "Peace & Carrots Camp" at Oakleaf Mennnonite Farm, my child will be participating in a week long day camp in 2013 at Berea Mennonite Church, Atlanta, Georgia.
Completion of this form gives medical authority to the adult representatives of the Oakleaf Mennonite Farm/Berea Mennonite Church.
By signing the bottom portion of this form, I am promising that the information above is accurate.
I also state, that if I allow my child to participate in “Peace & Carrots Camp", my child is physically fit and has the necessary skills to participate in this camp activity.
Signature of Parent/Legal Guardian: ____________________________________
Medical Treatment Authorization
Child’s Name:_________________________________________________
Mother’s Name:___________________________
Father’s Name: ______________________________
Home Phone Number: __________________________
Cell Phone Number: ______________________
E-mail: ______________________________________________________
Doctor’s name:______________________________
Doctor’s Phone Number: ___________________
Insurance Company:______________________________________
Insurance Policy #:______________________
Emergency Contact Person
In an emergency, if a parent or legal guardian cannot be contacted, the following individual has the authority to make decisions regarding my child:
Name: _________________________________________
Phone #: __________________________
Relationship to Child: ________________________________________________________
IMPORTANT – THIS SECTION MUST BE COMPLETED FOR ATTENDANCE
I understand that there are always risks inherent in camp activities, therefore, I agree to release and not hold Berea Mennonite Church and its ministry representatives liable for accidents that may occur on or off the church property during my child’s stay. The health history provided above is accurate as far as I know, and the child herein described has my permission to engage in all prescribed retreat activities except as noted.
Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp Director to secure and administer treatment, including hospitalization and anesthetization, for the child named above. I also understand and agree to abide with my physician’s recommendations.
Signature of Parent/Guardian: ___________________________________________________
Witness: __________________________________ Date:___________
************************************************************
Child’s Name:___________________________________
Grade: _____Date of Birth:_______________
We ask that you administer any medication to your child at home before or after camp. If necessary please complete a line for each medication sent with the child to camp. All medication must be in original containers with the prescription instructions from your child’s pediatrician, in your child’s name. It must be checked in with a member of the "Peace & Carrots Camp"/Oakleaf Mennonite Farm staff upon arrival.
I hereby request and authorize the Oakleaf Mennonite Farm staff, to give the following medication(s) to my child:
Currently taking any medication? Yes or No If yes, what?
NAME OF MEDICATION DOSAGE FREQUENCY WHAT IT’S FOR?
______________________________________________________
______________________________________________________
______________________________________________________
List Allergies (Food, drugs, etc...)
______________________________________________________
______________________________________________________
______________________________________________________
Medical Conditions (Diabetes, Epilepsy, Asthma, Fainting, Heart Condition etc…)
______________________________________________________
______________________________________________________
______________________________________________________
Are the student’s immunizations up to date? Yes or No
Does your child dehydrate easily? Yes or No
Can your child take part in athletic activities including jumping, running, swimming, and water sports?
Yes or No
If No please list:
______________________________________________________
As the parent (or legal guardian) of __________________________________, I certify that I have been
informed that, as a participant in "Peace & Carrots Camp" at Oakleaf Mennnonite Farm, my child will be participating in a week long day camp in 2013 at Berea Mennonite Church, Atlanta, Georgia.
Completion of this form gives medical authority to the adult representatives of the Oakleaf Mennonite Farm/Berea Mennonite Church.
By signing the bottom portion of this form, I am promising that the information above is accurate.
I also state, that if I allow my child to participate in “Peace & Carrots Camp", my child is physically fit and has the necessary skills to participate in this camp activity.
Signature of Parent/Legal Guardian: ____________________________________
Medical Treatment Authorization
Child’s Name:_________________________________________________
Mother’s Name:___________________________
Father’s Name: ______________________________
Home Phone Number: __________________________
Cell Phone Number: ______________________
E-mail: ______________________________________________________
Doctor’s name:______________________________
Doctor’s Phone Number: ___________________
Insurance Company:______________________________________
Insurance Policy #:______________________
Emergency Contact Person
In an emergency, if a parent or legal guardian cannot be contacted, the following individual has the authority to make decisions regarding my child:
Name: _________________________________________
Phone #: __________________________
Relationship to Child: ________________________________________________________
IMPORTANT – THIS SECTION MUST BE COMPLETED FOR ATTENDANCE
I understand that there are always risks inherent in camp activities, therefore, I agree to release and not hold Berea Mennonite Church and its ministry representatives liable for accidents that may occur on or off the church property during my child’s stay. The health history provided above is accurate as far as I know, and the child herein described has my permission to engage in all prescribed retreat activities except as noted.
Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp Director to secure and administer treatment, including hospitalization and anesthetization, for the child named above. I also understand and agree to abide with my physician’s recommendations.
Signature of Parent/Guardian: ___________________________________________________
Witness: __________________________________ Date:___________
************************************************************
Kindly mail the "PEACE & CARROTS" registration form and health history form to:
Andrew Toney
Summer Camp Coordinator
Berea Mennonite Church
Berea Mennonite Church
1088 Bouldercrest Drive S.E.
Atlanta, GA 30316
If you have any questions, please email peaceandcarrotscamp@gmail.com or call 404-981-3655.
