Circle Six Ranch Baptist Camp                                                                                               

Registration/Health/Medical Release

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

NOTICE:  This form MUST be notarized (see bottom of page).

Name _____________________________________________ Age __________ Date of Birth ___________________________

Address ___________________________________________ City ________________ State _____________ Zip ___________

Social Security # ____________________ Counselor ________________________ Church ___________________________

In case of emergency, whom shall we notify?

Name ____________________________________________________________ Relationship ___________________________

Address ___________________________________________ City ________________ State _____________ Zip ___________

Home phone ________________________ Cell phone ________________________ Work phone ______________________

Medical Information and Authorization

(If camper is under 18 years of age, this section must be completed by a parent or legal guardian.)

Medications needed: ______________________________________________________________________________________

                                    (All medications must be placed in the First Aid Station and be dispensed under adult supervision.)

Allergies: _______________________________________________________________________________________________

                                    (Please list all known allergies)

Personal Immunization Record (List dates or attach a copy of record.):           Date of last tetanus shot: ______________

This information is REQUIRED for child to be able to remain on the campground.

m DTP                                 ____________________        m Polio                                 ____________________        m Td                      _____________________

m DTP Booster    ____________________        m Polio Booster  ____________________        m Other                                _____________________

m HibCV                ____________________        m MMR                  ____________________        m Date of Measles Illness _______________

m HibCV Booster                ____________________       m MMR Booster ____________________        m Date of Mumps Illness ________________

Family physician _____________________________________________________ Phone ______________________________

CSRBC has permission to use any photographs/videos of person listed on this form for brochures, videos, advertising, web page or other promotional items.  I/we further understand that these photos/videos will only be used for CSRBC promotional purposes.

Check appropriate area, thereby giving parental consent for child to participate in special activities:

m  Paintball Course                                           m  Extreme Obstacle Course                                         m  Ropes Challenge Course

I authorize medical and/or surgical treatment in the event of an emergency for my child/me by a physician and medical facility chosen by the camp administration.  This is the original form or a facsimile of the original, signed form.

The information requested on this form is required by the Texas Department of Health and the Texas Youth Camp Health Safety Act.  This completed, signed form is required for everyone under the age of eighteen (18) years of age for registration at Circle Six Ranch Baptist Camp.  Minors will not be allowed to remain on the grounds without this completed, signed form.  There will be no exceptions.  The camp carries an accident policy on registered guests.  This policy is intended as a supplement to your own insurance and will pay only to its limits.  There is no deductible.  Pre-existing conditions are not covered.  This policy will pay only for accidents immediately reported to the camp.  This insurance does not cover members of your group who may leave the grounds during your scheduled stay.  Unauthorized activities may not be covered.  All claims must be reported on forms provided by the camp.

Parent/Legal Guardian signature (camper signature if camper is 18 years of age or older: ______________________________________

Date ___________________ Home phone ____________________ Cell phone ____________________ Work phone _______________________

Home address _______________________________________ City ________________________ State _______________ Zip _________________

Parent/Legal Guardian medical insurance co. ______________________________________Policy # __________________________________

_{~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~}

STATE OF TEXAS

COUNTY OF __________________________

Before me, the undersigned, a Notary Public in and for said County and State, on this day personally appeared

____________________________________________________, known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she executed the same for the purpose and consideration therein expressed.

GIVEN UNDER MY HAND AND SEAL OF OFFICE this ___________ day of ____________________________ A. D. _______________

_______________________________________

Notary Public

___________________________ County, Texas

6.1.10

Circle Six Ranch Health Form (Word 07)