EmailMe Form - Camp CYOKAMO Registration Form 2024

Name *

First Last

Gender *

Male

Female

Grade Entering in the Fall *

Age *

Shirt Size *

Have you been baptized? *

Yes

No

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian #1 Name *

First Last

Parent/Guardian #1 Phone *

### - ### - ####

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Phone

### - ### - ####

Emergency Contact Name *

First Last

Emergency Contact Relationship *

Emergency Contact Phone *

### - ### - ####

Child is attending with Carterville Christian Church

Child is attending the following camp *

Minister Name *

Gwenn Utter (K-5th Grade)

Jordan Woodring (6th-12th)

Student Medical Information

***All medicine is to be left with and dispensed by the camp staff.***

Prescriptions Currently Taking:

	Prescription Name	Dosage	Instructions
Prescription #1
Prescription #2
Prescription #3

Last Tetanus Booster *

Known allergies and reactions *

Other Health Concerns *

Recent surgery, injury or condition that might restrict your child from participation in camp activities *

Physician Name *

Physician Phone *

### - ### - ####

Medical Insurance Company *

Medical Insurance Group/Policy Number *

Medical Insurance Company Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Medical Insurance Company Phone *

### - ### - ####

CYOKAMO PERMISSIONS

• I allow my child to leave the CYOKAMO campus for off-campus activities during the week of camp.

• I allow CYOKAMO to use photographs or video footage shot at camp of my child for the use of promotional materials.

• I allow CYOKAMO Camp Management to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named on this form. I understand that every effort will be made to contact me in case of such an emergency and, if possible, before any such medical treatment is administered. I release the camp from any responsibility other than normal supervision and care. In case of accident, I will not hold CYOKAMO or any staff members, management, or officers liable unless guilty of negligence.

• All of the above medical information on my child is correct.

• In consideration of the privilege of participating in CYOKAMO recreational activities (including Archery Tag): Guest agrees to exercise caution and to obey all instructions of the CYOKAMO Staff. I give permission for any medical treatment that the CYOKAMO staff may deem necessary in case of emergency. Guest (and Guest’s parent or legal guardian, if Guest is under 18) UNCONDITIONALLY RELEASES AND ABSOLVES Camp CYOKAMO, its staff, cooperative churches and all other persons from any and all liability in connection with any injury or death of Guest, or damage to property, sustained while participating in CYOKAMO recreational activities (including Archery Tag), including specifically any negligence of Camp CYOKAMO and its staff: and agrees to INDEMNIFY AND HOLD HARMLESS Camp CYOKAMO and the cooperative churches, its staff, and all other persons from any and all damages, costs, and expenses that any of them may incur in connection with, therewith, including for their own negligence, or in connection with evacuation or medical treatment.

I have carefully read, understand and agree to the above statements.

CYOKAMO Permissions: Parent/Guardian Signature *

Clear

Date Time *

MM / DD / YYYY

C3 Over the Counter Consent

I give permission for a member on staff at Carterville Christian Church (C3) to provide over the counter medications to the named participants above per necessity only, unless otherwise previously stated in allergies or medical alerts.

Over the Counter Consent: Parent/Guardian Signature *

Clear

Date Time *

MM / DD / YYYY

C3 Consent

As the parent or legal guardian of the above named minor, I give my permission for him or her to participate in activities, events and programs with Carterville Christian Church (C3). I understand the inherent risks that are involved in these activities and hereby release C3, its staff, employees and these activities, events and programs. Further, I do authorize the minister, adult, leader, or sponsor of the activity, event, or program, in the event I cannot be reached by phone, to give consent to a physician and or hospital for emergency medical or surgical treatment. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment. Further, I authorize C3 to use photographs and video footage of the participant.

C3 Consent: Parent/Guardian Signature *

Clear

Date Time *

MM / DD / YYYY