Camper's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address *

Same address as camper

Different address as camper

Parent/Guardian Phone *

(###)

###

####

Address (If different from Camper)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

For Parents/Guardians and Camper: *

Searchlight to Spotlight Summer Camp may use any photos and videos taken of the applicant at any camp event in its publications or those of its sponsors.

Yes

No

*

The undersigned hereby agrees to release and hold harmless Christian Ambassadors Inc., Independent Church of God Atlanta, Church of God International, and their current or former directors, officers, employees, successors, assignees, agents, volunteers, and legal representatives from all claims, causes of action, damages, suits or demands of any nature whatsoever, in law or equity, known or unknown, contingent or liquidated, arising out of the camper’s participation in camping at Searchlight to Spotlight Summer Camp in Lafayette, GA. Further, the undersigned acknowledges that this release waives any legal rights the undersigned and the camper may have against Christian Ambassadors Inc., Independent Church of God Atlanta, Church of God International, their current or former directors, officers, employees, successors, assignees, agents, volunteers, and legal representatives for any injury or loss which the undersigned or camper may sustain in connection with or because of the camper participating in this camp.

Agree

*

We have set forth specific behavioral guidelines for campers to follow during their camp program. Campers and their parents/guardians must agree before camp attendance and submit an answer of "Yes" to be allowed to participate at camp. If the camper fails to abide by the behavioral guidelines, the camper may be immediately expelled from camp, or the parent/guardian will be notified by phone and asked for assistance in helping their camper make more positive choices. If the camper's behavior does not improve, the camper will be asked to leave camp. Parents are responsible for their camper's travel to/from camp. Campers asked to leave camp early for behavioral reasons may not attend a camp with us for 1 year. If the camper wishes to return to one of our camps after that year, they must set up an interview with the Camp Director to discuss behavioral expectations. Below is a list of our behavioral expectations. Please read them aloud to your camper and choose from below as evidence of your and your camper's agreement. You will be required to acknowledge these guidelines once more at drop-off/registration. ● Campers agree to abide by the rules and regulations of the camp and are expected to follow the directions and guidance provided by the camp staff. ● Campers will not engage in any activity that may put themselves, other campers, or staff at risk, including hitting, kicking, biting, or pushing another camper or camp staff, possession or use of weapons, use of illegal drugs or other controlled substances, use of tobacco products of any kind, and consumption of alcoholic beverages. ● Campers will remain in the presence of camp staff at all times unless given permission to travel in the main camp area with a camper buddy appointed by the staff. ● Campers will treat everyone in the camp community with respect at all times, including respecting others' personal belongings, privacy, and feelings. ● Campers will not use obscene or foul language or gestures and will not threaten to harm themselves or others. ● Campers will respect the camp's facilities and equipment and will not take or destroy camp property. I have read and understand these behavioral expectations, and I agree to abide by them at all times during my stay at camp.

Agree

Emergency Contact One *

First Name

Last Name

Emergency Contact One Phone *

(###)

###

####

Emergency Contact Two *

First Name

Last Name

Emergency Contact Two Phone *

(###)

###

####

Checkbox *

Is camper covered by medical insurance?

Yes

No

Does your camper have medication requirements while at camp? *

Yes

No

PERMISSION TO SECURE EMERGENCY SERVICES: *

I am giving my consent in advance for medical treatment at an appropriate medical facility in case of illness or injury of my camper. I will be responsible for the cost of such services if not covered by my insurance. Acknowledgment by signature required at drop-off/arrival.

Agree

RELEASE OF LIABILITY REGARDING SPECIAL HEALTH CONDITIONS *

I agree to hold harmless and indemnify Christian Ambassadors, Inc., Independent Church of God Atlanta, Church of God International, and their current or former directors, officers, employees, successors, assignees, agents, volunteers, and legal representatives from any and all liability, loss, damages, costs, or expenses sustained, incurred, or required arising out of the camper's actions during the camp/event.

Agree

"I attest that all medical information and release forms are correct." *

Agree

"I am stating that I am aware of and accept the risk inherent in the program activity." *

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Searchlight to Spotlight Summer Camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Church of God International, Independent Church of God Atlanta, Christian Ambassadors and all their respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against The Church of God International, Independent Church of God Atlanta, and Christian Ambassadors including all counselors and staff, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death. Outdoor Programming Release and Authorization I acknowledge that my child will attend camp with access to an outdoor environment and may be exposed to the following: • Domestic or wild animals • Poisonous and venomous species including insects and plants (poison oak, wild mushrooms) • Allergens and items commonly associated with allergies (animal dander, plant pollen, nuts, etc) • Inclement weather exposure, including sun, wind, snow, rain, sleet, heat, smoke, earthquakes, and other weather-related conditions. • Hazardous materials such as garbage, broken glass, or any other materials left behind in public parks. I acknowledge that camp may include potential hazards such as: • Shared use of public space (trails, beaches, meadows, picnic areas) • Interacting with the general public • Toileting and hand washing in a publicly serviced restroom • Hand washing in the field may have limited access to running or clean water, and may include the use of hand sanitizer when no other options are available. I recognize that my child may engage in age-appropriate permitted activities including: • Hiking or strolling on public trails, sidewalks, access roads, and paths • Accessing bodies of water such as mud puddles or seasonal spring runoff creeks • Campfires in designated areas, monitored by staff at all times. This includes the use of a camp stove or barbecue. • Tree climbing, as permitted under the supervision of staff, adhering to any rules or regulations of the public specific to our location. • Climbing on objects that include but are not limited to logs, rocks, and stumps • Jumping from appropriate heights without the use of a fall zone when in the field • Manipulating real tools, including hammers & nails, saws, hand drills, hot glue guns, permanent markers, ropes, scissors, child-safe kitchen tools, and more with appropriate adult instruction and supervision. • “Puppy play,” also called rough-and-tumble play, including but not limited to tumbling, wrestling, rolling, and running. • Foraging for, harvesting, and eating plants both in the wild and from our own community garden. • Playing with, building with, and using sticks, pallets, cable spools, larger wood planks, stumps, and other “loose parts” deemed appropriate by our caregivers • Creating an inclusive environment with children whose background, behavior, developmental ability, and home culture may differ from my own child’s • Developing body awareness and senses through activities such as walking barefoot and using all our senses for safe observation of the world around us. I, as the parent or guardian of the child listed, fully understand the risks of camp in a predominately outdoor setting. I will contact my child’s primary caregivers or the Director with any concerns. I have read the above waiver and agree to allow the child listed below to attend and fully participate in any and all of the above listed activities under the supervision of the Caregivers who have been trained in risk policies and procedures. Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Agree

Date *

MM

DD

YYYY