(check one)
o All High School Events
o Specific Event Only __________________
Date (if applicable): ______________
1st Student Name
2nd Student Name
3rd Student Name
4th Student Name
Grade ______
Grade ______
Grade ______
Grade ______
____________________________
____________________________
____________________________
____________________________
Age
Age
Age
Age
_____ Birthday ___________________
_____ Birthday ___________________
_____ Birthday ___________________
_____ Birthday ___________________
Home Phone ___________________________________________________________________________________
Cell Phone _____________________________________________________________________________________
Emergency Contact _____________________________________________________________________________
Emergency Number _____________________________________________________________________________
Address ________________________________________________________________________________________
City _____________________________________________________ Zip _________________________________
I authorize the participation of my child in all activity sponsored by Five14 Church. I am aware of the special
dangers and risks inherent in participating in the activity including physical injury, death, or other
consequences arising or resulting from the activity. I agree to accept responsibilities. I further agree to
advise activity planners and sponsors of any physical or mental limitations my child may have. I agree to be
fully responsible for my own property and equipment related to this activity.
In consideration of and part of a right to participate in this activity, I hereby release and indemnify Five14
Church and event sponsors of any and all liability, claims and causes of action arising out of or in any way
connected with my participation in this activity.
I also agree that, in the event medical treatment is required, medical personnel may provide care necessary,
including hospitalization, anesthesia, injection, or surgery for my child’s wellbeing. I agree to accept
responsibility for any medical costs that may result. I hereby agree to indemnify and hold harmless Five14
Church, and its officers, employees, and volunteer staff from any liability.
Participant Name: _______________________________________________________________________________
Participant Signature: (parent/guardian if minor or child) _____________________________________________
Date: __________________________________________________________________________________________
Name: ______________________________________________________________
First
Middle
Last
❒ Male ❒ Female
Birth date: ______________
Camp Attending: ❒ HSC Beach
❒ HSC Mountain
__________________________________________________________________________________________
Street address
City
State
Zip
First
Parent/legal guardian/spouse to be contacted in case of illness or injury:
Name: _______________________________________________________ Phone number: (____) ____-______
Relationship to attendee: ____________________
Home address:
__________________________________________________________________________________________
(if different from above)
Street address
City
State
Zip
Diet, Nutrition: ❒ This attendee eats a vegetarian diet.
❒ This attendee eats a gluten free diet.
(Please describe below)
Middle
Allergies: ❒ No known allergies. ❒ Attendee is allergic to: ❒ Food ❒ Medicine
(If attendee has allergies, please describe what the camper is allergic to and the reaction seen.)
❒ This attendee eats a peanut free diet.
❒ This attendee has special food needs.
Last
Authorization and Indemnification
Restrictions
Any restrictions and limitations of my student are solely the responsibility of the church my
student is attending High School Camp with. I hereby acknowledge and agree that High
School Camp is not responsible for any restrictions or limitations of my student’s activities.
Photo Release
I hereby grant to High School Camp the right to use, reproduce, and/or distribute
photographs, films, videotapes, and/or sound recordings of the my student, without
compensation or approval rights, for use in materials promoting the activities of High School
Camp.
Attendee signature _________________________________________________
(if over 18 years of age)
Signature of
Parent/Legal Guardian _________________________________________________
© 2014 The reThink Group, Inc.
2015 High School Camp Release Form
Date ______________
Date ______________
Rev. 11/2014
Church Name: ________________________________
Acknowledgement of Inherent Risk
I acknowledge and understand there are inherent risks associated with many camp activities.
I assume the risk associated therewith, whether known or unknown to me at this time. I
hereby release High School Camp, including its employees, agents, volunteers, and trustees,
from all claims, liability, and responsibility for physical injury, including death or illness, and
loss of personal property while at camp. This release is binding upon all claims that may be
brought by my student’s family, estate, heirs, personal representative(s), or assigns.
Name: ______________________________________________________
Attendee Home address:
Why Here: Three water parks. Ten indoor and outdoor thrill rides. A 10,000-‐foot wave pool. A 19,000-‐gallon surfing experience. HSC MOUNTAIN promises to present a different adventure every day. The deluxe, mountain-‐
resort accommodations make for a memorable week that is sure to bring small groups closer together. With a backdrop provided by the Blue Ridge Mountains, students will be inspired to encounter God in a whole new way. The HSC team is thrilled to welcome you to HSC MOUNTAIN in Pigeon Forge, TN. Dates and Location: July 13 – 17th 2014 Wilderness at the Smokies Pigeon Forge, TN www.highschoolcamp.com Accommodations: We are staying at the Wilderness at the Smokies located at 1424 Old Knoxville Highway, Sevierville, TN 37876. There are two resort hotel buildings on the property. They all have a luxury mountain/log-‐
cabin feel. Most rooms sleep 6 (a bunk and two queens or something similar). For more information go to http://www.wildernessatthesmokies.com Food In addition to the three meals provided daily, there is a coffee shop, a deli, a snack bar, and a restaurant on the property. Make sure you bring an average of $50 for extra spending money. Fun We know that a boring camp means nobody wins. That’s why the HSC team is made up of the craziest, most creative, most wildly inventive people we can find. From a camp host who will keep you ROTFLing to competitions that are all-‐out war, this will be the most FUN event of your student’s summer. Free time At HSC Mountain there are indoor and outdoor water parks. While we want to offer students some free time to enjoy the great amenities of each location, we also realize that too much of a good thing isn’t such a good thing. So, there will not be long stretches of free time every day. Some days will include a structured, team-‐building recreation time as well. What’s Next? Complete the following things to reserve your spot today! • Five14 Church Permission Slip • High School Camp Consent Form • Minimum $50 (non-‐refundable) Deposit Give these items to Caylee Whipple on a Sunday morning at Five14, or drop them off to the church offices (97 E Main Street, New Albany), or mail them to P.O. Box 361 New Albany, 43054. Email [email protected] with any questions. Cost is $450 total including a $50 deposit (non-‐refundable) DUE by March 15th, to hold your spot. All monies are due by May 17th, 2015. We leave Monday, July 13th at 8 AM from the Five14 Church offices. • Pack one suitcase & feel free to bring a backpack and pillow. • Don’t forget to bring money for travel meals (average $50 cash for three fast food meals-‐
snacks).`