Demo Form Woody Acres Camper Registration Step 1 Step 2 Step 3 Campers Name Age Gender Male Female Birthdate Please note: All t-shirts will be ordered in youth sizing. T-shirt Size Small Medium Large XL 2XL 3XL Other Roommate Request Parent / Guardian Phone Cell Phone Emergency Contact Valid Email Address Address City Province Postal Code Please state the week you are applying for: August 7-14 Junior Camp August 14-21 DiscipleTrek Camp Class Selection (Please choose all preferred classes) Please note that this selection does not guartantee class placement. Class requests will be filled upon availability. Waterskiing Wakeboarding Rockwall Archery Ceramics Painting Crafts Sports Photography Music Of the choices made for Class Activities please place in order from 1 to 10 your preference - 1 being the lowest and 10 being the highest. Is your child able to swim without a lifejacket? Yes No Is your child afraid of water? Yes No Is your child afraid of heights? Yes No Is your child willing to run? Yes No Comments Step 2 Name Age Medicare # Expiry Date Parent / Guardian Phone Address Family Doctor Phone Address List any known allergies. List any medications List any special diet Are immunizations up to date? Yes No Medical Historyi Has camper ever had or been diagnosed with any of the following? Diabetes Insulin Dependent Bedwetting Frequent Sore Throats Abscessed ears Stomach upset Ear ache Asthma Bronchitis Constipation Menstrual problems Sinusitis Frequent colds Headache High Blood Pressure Fainting / Dizziness Kidney Trouble Sleep walking Bleeding / Clotting Disorder Back / Joint Pain Recent Injury Epileptic seizures Date of last seizure Has the camper ever been treated for ADD or ADHD? Yes No Date last medicated Emotional / behavioral difficulties, or eating disorder? Yes No Had a significant life event that might affect the camper while at camp? Yes No If you answered yes to any of the above, please explain: Please list any restrictions or adaptations the camper may require while at camp. I, the undersigned parent or guardian of Camper named in this form, do hereby consent, for the duration of the camp, to any X-ray examination, anesthetic, medical or surgical diagnoses or treatment and hospital service that may be rendered to said minor under the general or specific instructions of any physician or at any licensed hospital. It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize the camp director and/or camp medical staff or the physician to exercise their best judgment to the requirement of such diagnosis or treatment. We hereby authorize any hospital, physician or other person who has attended or examined the minor to furnish to the Insurance Services or its representative, any and all information with respect to any illness, medical history, consultation, prescriptions or treatment and copies of hospital or medical records. A photocopy of this authorization shall be considered as effective and valid as the original. Step 3 Campers Name PHOTO RELEASE Slides, video recordings, sound recordings, and photographs taken at Woody Acres Camp during the 2022 Camp Season may be used in news articles, visual aids, or promotional materials; unless otherwise requested. Yes my child’s picture MAY BE used. No, my child’s picture MAY NOT be used. By selecting this box I am acknowledging the choice I made for the Photo Release agreement. I consent to allow my child to participate in activities taking place at Woody Acres Camp. I realize that the activity program can involve risks and as such, I release Woody Acres Camp, the Seventh-day Adventist Church in Newfoundland and Labrador Mission Office and its officers and directors from any responsibilityfor injuries sustained while involved in the activity programs of the camp, as well as incidents beyond the control of the camp staff. Please choose one of the following options: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. Restrictions or Adaptations By selecting this box I am acknowledging the choice I made for the Woody Acres 2022 Activity Program Consent and Release Form. Visitors to Camper: Although visitors are unlikely at camp, please check your preference. There are no restricted visitors to my child while at Woody Acres. My child is not to have contact with the name(s) listed below while at Woody Acres Camp. Contact Restriction List Please provide names that your child is not to have contact with while at Woody Acres Camp. By selecting this box I am acknowledging the choice I made for the Visitors to Camper selection. Camper Pick Upi Name of person or persons authorized to pick up my child at the end of camp. By selecting this box I am acknowledging the person or persons I have selected to pick my child up at the end of camp. Please make sure camper is signed out at the office prior to departure on Sunday Human Check 5 + 6 = By clicking on "Next" you will submit this portion of the Woody Acres Registration form. You will then be redirected to the Medications portion of the form followed by Payment options.
