938 Chicopee Street 01013

Chicopee, MA

iCNC Youth Summer Camp Registration & Medical Form August 10-13, 2011
Please complete form in its entirety and with accurate information. Print using blue or black ink. Any additional questions regarding registration form and/or Youth Summer Camp 11 can be addressed to Stan Belyshev at (413) 364-7870.

Camper Information: ***(If you are under the age of 18, then a parent or legal guardian needs to fill out this form)***
Name: Address: Phone #: Parent/Guardian Contact Information: Name of Parent(s)/Guardian(s): Address: Daytime Phone # ( H / W / C ): Health Information: Youths PCP/Practice Name: Insurance Provider: Known Allergies (food/medication): Chronic Medical Problems/Illnesses: Current Medication(s)/Dosage (circle one: over-counter/prescribed): Emergency Contact (please provide TWO different contacts): Name: Contact #: Name: Contact #: Alt. #: Alt. #: Relationship: Relationship: Office Phone #: Policy #: City/State/Zip: Alt. Phone # ( H / W / C ): Relationship: Birth Date: City/State/Zip: Email Address: Age:

International Church of the New Covenant

Youth Summer Camp 2011 Registration and Medical Form April 2011

Waiver:
I, _______________________________________, am either an emancipated adult or the parent or guardian of a minor child who will be participating in the iCNC Youth Summer Camp 2011 event. I am fully aware that my own/my child's participation in this event is totally voluntary. In consideration of iCNCs agreement to permit me/my child to participate in Youth Summer Camp 2011, the receipt and sufficiency in which consideration is hereby acknowledged, I agree as follows: I, individually, and on behalf of my minor child, if applicable, and our respective heirs, successors, assigns and personal representatives, hereby: 1. Release, acquit and forever discharge iCNC and their employees, agents, servants, officers, trustees and representatives, in their official and individual capacities, from any and all liability whatsoever for any and all damages, losses or injuries to persons or property or both which arise out of, during or in connection with my/my child's participation in Youth Summer Camp 2011, which may be sustained or suffered by me/my child or any person in connection with my/my child's association with, or participation in, activities at, sponsored by, or arising out of my/his/her travel to or from Youth Summer Camp 2011; 2. Agree to indemnify, defend and hold harmless iCNC and their employees, agents, servants, officers, trustees and representatives, in their official and individual capacities, from any and all liability, loss or damage they incur or sustain as a result of any claims, demands, actions, causes of action judgments, costs or expenses, including attorneys fees, which result from arise out of relate to my/my child's participation in Youth Summer Camp 2011 including my/his/her travel to or from Youth Summer Camp 2011. I hereby acknowledge and accept that: 1. There are certain risks arising from various activities, including but not limited to bodily injury, that could result from my/my child's participation in Youth Summer Camp 2011. I have knowingly and voluntarily decided to assume the risks of these inherent dangers in consideration of iCNCs permission to allow me/my minor child to participate in Youth Summer Camp 2011; 2. My and, if applicable, my child's personal property is at my risk entirely; 3. iCNC reserves the right to decline to accept or retain me/my child in Youth Summer Camp 2011 at any time should my/his/her actions or general behavior impede the operation of Youth Summer Camp 2011 or the rights or welfare of any person. I understand that I/my child may be required to leave Youth Summer Camp 2011 in the sole discretion of iCNCs agents and representatives. In such an event, no refund will be made for any unused portion of Youth Summer Camp 2011. I understand that iCNC, in its sole discretion, reserves the right to cancel Youth Summer Camp 2011 or any aspect thereof prior to commencement. I represent and warrant that I am/my child is covered throughout Youth Summer Camp 2011 by a policy of comprehensive health and accident insurance which provides coverage for injuries which I/he/she may sustain as part of my/his/her participation in Youth Summer Camp 2011. I agree to complete the HEALTH INFORMATION above to the best of my ability and, by its completion, I hereby release and discharge iCNC of all responsibility and liability for any injuries, illnesses, medical bills, charges or similar expense/he/she may incur while participating in Youth Summer Camp 2011. By completing the form, I hereby authorize iCNC to obtain any necessary medical treatment to myself/my child, consent to any necessary examination, treatment, or care under the supervision and/or advice of any properly licensed medical professional and explicitly authorize iCNC to release medical information about me/my child to any person or entity to whom iCNC refers me/my child for medical treatment. I agree that this Agreement is to be construed pursuant to the laws of the Commonwealth of Massachusetts and is intended to be as broad and inclusive as permitted by law, and if any portion hereof is held invalid, it is agreed that the balance hereof shall continue in full legal force and effect. In addition, I agree that any legal action arising out of or in relation to this Agreement must be brought in a Hampden County, Massachusetts court. I hereby grant to iCNC my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child's name, voice, image, and/or likeness that arises from his/her participation in Youth Summer Camp 2011, whether still or motion pictures, audio or video tape, for promotional, instructional, business or any other lawful purposes, at iCNCs sole discretion.

In signing this Agreement, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights as well as, if applicable, those of my child, that it is a binding Agreement, and that I have signed it knowingly and voluntarily. Signed: Date:

International Church of the New Covenant

Youth Summer Camp 2011 Registration and Medical Form April 2011

Printed Name:

iCNC Youth Summer Camp RULES and REGULATIONS Agreement

1. Registration and Admission: All campers MUST fill out the iCNC Registration and Medical Health Form as well as the two required forms for Geneva Point Center, including the Doctor Signed Form and the Camper Health History Form. Additionally, all campers must have payment submitted in full prior to the actual camp date. 2. Directives from Camp Staff: All campers are to report directly to their assigned group leader and are expected to comply with all leaders and camp staff at all times. Campers are to comply with all scheduled activities, meals, services and curfew times. All registered iCNC campers are not allowed to leave Geneva Point Center grounds without proper authorization. Failure to comply with any of the aforementioned rules will result in disciplinary action, which can include verbal warnings, exclusion from certain activities or EXPULSION from the campsite without reimbursement of camp fee. 3. Respect of Property: Campers are expected to respect the property of those around them, Geneva Point Center facilities, and the natural surroundings of the campground. Campers are responsible for their own property. Anyone found defacing anything that does not directly belong to him/her will be responsible for the value of the damage incurred. Further disciplinary action may be taken by either Geneva Point Center or iCNC staff. 4. Prohibited: There will be absolutely NO guns, knives or weapons of any kind permitted at Geneva Point Center. Drugs, tobacco, alcohol, fireworks, matches and/or lighters are strictly prohibited. Fighting between campers, sexual conduct and pranks will not be tolerated and appropriate disciplinary action will be taken. ANY CAMPER FOUND IN POSSESSION OF ANY OF THE AFOREMENTIONED OBJECTS OR VIOLATING THE ABOVE RULE WILL BE IMMEDIATELY REMOVED FROM THE CAMP PREMISES!!! NO EXCEPTIONS!
REGISTRATION AGREEMENT I have read and understood the camp rules and regulations. I agree to follow all rules as a camper of iCNC Youth Summer Camp 2011 at Geneva Point Center.

Camper Signature

Date

I, the parent/legal guardian of the camper, do hereby verify that I have read and understood the rules and regulations of the camp. I understand that, if the rules are disregarded, the camper will be subject to

International Church of the New Covenant

Youth Summer Camp 2011 Registration and Medical Form April 2011

disciplinary action, including expulsion from the campground. Furthermore, I accept full responsibility for any property the camper should deface or damage beyond the normal wear and tear.

Parent/Legal Guardian Signature

Date

International Church of the New Covenant

Youth Summer Camp 2011 Registration and Medical Form April 2011