Registration - Redeemed Ranch

SUMMER CAMP T-SHIRT (circle one size)
Youth - S M L Adult - S M L XL 2X
(T-Shirt is free if registered by March 31,2015, otherwise t-shirt is $20.)
CD of pics of camper week - $15 _________
8 x 10 GROUP photo - $15 _________
REDEEMED RANCH CAMP 502 Woodmill Rd. Heflin, LA 71039 Phone (318) 470-­‐7917 2015 Camper Registration / Horse Rental Agreement & Activity Waiver/Release Form
Please check camp attending _
June 1-5 ALL GIRLS “Horsemanship”
(ages 9-15) ______
July 6-10 ALL GIRLS “Horsemanship” (ages 9-15) _______
June 15-19 “Home on the Ranch” (Boys/Girls ages 8-12) ______ July 20-24 “Home on the Ranch” (Boys/Girls ages 8-12) ______
NEW!! (3 day camps!) July 1-3 Boys/Girls ages 7-12 __________ July 27-29 ALL Girls ages 9-15 __________
Parents/LegalGuardians
Please return this “Camper Registration / Horse Rental Agreement & Activity Waiver/Release Form” with a
non-refundable $75.00 deposit to the above address as soon as possible to reserve your camper’s session. ($75 deposit will be deducted from camp fee.)
Balance can be paid before or upon arrival. Please keep - “Camper Information/Items to Bring” sheet along with RRC map for packing.
Payment: Check (payable to Redeemed Ranch Camp), PayPal, or Debit/Credit Card (add 3% if using PayPal or Debit/Credit Card)
Name on card - _________________________ Address on card ____________________________________________________
Debit/Credit Card - #________ ________ ________ _________ Exp. date ____ ____ CVV (3 numbers on back of card) ______
Camper’s Name
______________________ ______________________ ______
LAST
FIRST
M.I.
Gender: Male Female
Date of Birth ______
Age ____
Camper’s Street Address: ______________________
Grade in Fall _____
City: __________ ST: ____ Zip: _________
This camper lives with: ____both parents _____father _____mother
other: ______________________
1. Custodial Parent/Guardian Name: _____________________Home Phone # __________ Cell Phone #___________
Home Address _______________________________________________________
Employer: ___________________________ Work Address________________________ Work Phone# __________
Parent’s e-mail: _______________
2. Second Parent/Guardian Name: ______________________ Home Phone # __________ Cell Phone #___________
Home Address ________________________________________________________
Employer: ___________________________ Work Address________________________ Work Phone# __________
Parent’s e-mail: _______________
To:“Returning Camper”-if you bring a NEW camper friend, you’ll get a $50 discount (new camper(s) must attend 5 day camp week & new camper(s) must be registered by May 1, 2015
New Camper Friend (s) - _____________/______________ Bunk Mate(s) - ________________/______________________
LICE NOTICE: Please be aware that campers will not be allowed to stay at camp if they have lice nits in their hair. If your child
has been treated for lice prior to attending camp, please make sure they are nit-free before arriving at camp. This policy will ensure
that your camper is not embarrassed at camp.
INSURANCE INFORMATION – Please attach a photocopy of insurance card (front & back).
Is the camper covered by family medical/hospital insurance? ____Yes ____No
Insurance Carrier/Plan Name__________________________ Group #_____________________ Policy # ____________________
Name of Policyholder ________________________________ Social Security # _________________________________________
Parent/Guardian Authorizations
The information given in these (two page) forms are complete and accurate to the best of my knowledge. I hereby give my
permission for my camper to participate in all camp activities.
I hereby give my permission to Redeemed Ranch Camp staff and volunteers to administer prescribed medication,
provide health care, and seek emergency medical care. I hereby give my permission to Redeemed Ranch Camp to provide
or seek transportation to medical facilities for my camper.
In case of an emergency where I can’t be contacted, I hereby give permission to the physician selected by
Redeemed Ranch Camp to secure and administer proper treatment, hospitalize, order injections, order anesthesia
and/or surgery for my camper.
I hereby give my permission for Redeemed Ranch Camp staff to administer over-the-counter medications to my camper
as needed.
I understand that the Redeemed Ranch Camp Director reserves the right to send home a camper whose medical condition
becomes unmanageable and/or places the camper or Redeemed Ranch Camp at risk in the Camp environment.
PHOTO RELEASE – I give my permission for REDEEMED RANCH CAMP to use any photos, taken of me, my child or my family at any
REDEEMED RANCH CAMP event in their publications. I release my right to any kind of remuneration from said photos.
Authorization Signature (Parent or Guardian) _______________________________ Phone #____________
In Emergency, notify (print) __________________________Relationship -_________ Phone # _________________
Date -
DATE __________
Camper Last Name _____________________________ Camper First Name ___________________
Page 2
Date of Birth _____/_____/_____
HEALTH HISTORY
Name of Camper’s Physician _________________________________ Office Telephone ( _____) ___________________
Name of Camper’s Dentist ___________________________________ Office Telephone (______)___________________
Name of Camper’s Orthodontist _______________________________ Office Telephone (______)___________________
ALLERGIES – List all known.
Medication Allergies ___________________________ Reaction and Treatment ___________________________________
___________________________
___________________________________
Food Allergies _______________________________ Reaction and Treatment ___________________________________
________________________________
___________________________________
Other Allergies _______________________________ Reaction and Treatment ___________________________________
inc. plant,
______________________________
___________________________________
animal, etc.
*MEDICATION ( Please put ALL medication in a large ziplock bag with each medication marked with dosage and camper’s name.)
Please list ALL prescription medication, over-the-counter and non-prescription drugs taken routinely. Fill in the blanks completely. Bring
enough medication to last all week. Empty bottles will be returned to your camper. ALL DRUGS MUST REMAIN IN THE ORIGINAL
CONTAINER. ALL PRESCRIPTION MEDICATIONS MUST BE IN A PHARMACY LABELED CONTAINER WITH THE
CAMPER’S NAME ON IT. All medications (prescriptions and over-the-counter) must be turned in at check-in.
_____ This Camper does NOT take any medications on a regular basis.
_____ This Camper takes routine medication as follows:
Medication 1 ________________________________
Reason _____________________________________
Dose taken __________________________________
When taken each day __________________________
Medication 2 ________________________________
Reason _____________________________________
Dose taken __________________________________
When taken each day __________________________
Medication 3 _________________________________
Reason ______________________________________
Dose taken ___________________________________
When taken each day ___________________________
Medication 4 _________________________________
Reason ______________________________________
Dose taken ___________________________________
When taken each day ___________________________
CHRONIC CONCERNS
Check ALL that pertain to your camper and provide information about supportive health care:
_____ This camper has NO long-term health concerns and is capable of full participation in the camp program at Redeeemed Ranch Camp.
_____ This camper has the following health concern(s): (Please provide information about supportive health care needed for each checked item.)
_____Asthma (even if inhaler is only used occasionally) _______________________________________
_____Frequent ear infections ____________________________________________________________
_____Migraine headaches ______________________________________________________________
_____Enuresis (bed-wetting) ____________________________________________________________
_____Depression, ADD, ADHD, Oppositional Behavior Disorder _______________________________
_____Anorexia, Bulimia (Eating Disorders) ________________________________________________
_____Diabetes ________________________________________________________________________
_____Any other chronic illness such as Crohn’s Disease, Anemias, Seizures, Tourett’s, etc. ___________
______________________________________________________________________________
_____Fainting (for any reason) ____________________________________________________________
_____Sleepwalking _____________________________________________________________________
Please use this space to list or explain any additional information about which Redeemed Ranch Camp should be aware:
1) any restrictions on camp activities 2) the camper’s behavior and physical, emotional, or mental health
____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
IMMUNIZATION HISTORY
Has your camper been out of the USA in the last 9 months? ____ Yes ____ No
If yes, where?_______________________________
_____Yes _____No This camper has had chicken pox or varicella vaccination.
_____Yes _____No This camper has had mononucleosis in the past 12 months.
_____Yes _____No This camper has a history of illness, injury, surgery of has been hospitalized in the last year that will affect participation
in camp activities. If YES, please explain: ________________________________________________________
_____________ Date of last Tetanus shot
Horse Rental Agreement & Activity Waiver/Release Form
Please carefully read the following rental agreement and liability waiver for horseback riding and/or any activity at Redeemed Ranch Camp (herein called RRC)
before signing. At RRC we consider safety to be a top priority, so that all you/your child’s experiences will be pleasant. Thank you for your patronage,
we hope you/your child have a safe and enjoyable time. In consideration of the payment of a fee and the signing of this agreement, I, the following
listed individual, and/or the parent or legal guardians thereof if a minor, do hereby agree to hire from RRC a horse, tack and equipment, personnel
and trail for the purpose of trail/instructional riding on horseback:
Registration of Participants and Agreement Purpose
(Parents, if you have more than one child attending RRC, you can list them on this one form.)
Participant Name
Date of Birth/Age
1.
__________________
___________
2.
__________________
___________
Horse Riding Experience
(Check one that applies)
_____ Beginner (under 10 hrs.)
_____ Over 10 hrs.
_____ Beginner (under 10 hrs.)
_____ Over 10 hrs.
Protective Headgear
I have been fully informed by RRC that I can better protect myself against head injuries by wearing an approved protective equestrian headgear while mounting,
riding, dismounting and being around horses. Mark an “X” on the following page before the appropriate sentence which describes your decision regarding the
wearing of such equipment on the ride (s) in which you are contracting herein to participate:
____
I request that I/my child(ren) wear an approved protective equestrian headgear which RRC will provide, understanding that these may not be
of perfect fit for my head, and once provided I/my child(ren) will be responsible for securing the protective headgear on my/their head at all times.
____
I refuse that I/my child(ren) wear any type of protective headgear and I accept full responsibility for this decision.
____
I/my child(ren) will wear protective headgear which I, the undersigned, am providing and I will accept full responsibility for this decision. I am not
relying on RRC to determine my/my child(ren)’s headgear’s quality or suitability.
Saddle Girth Natural Loosening
I understand that saddle girths may loosen during a ride. If a rider notices this, he/she must alert the nearest guide or wrangler as quickly as possible so action can
be taken to avoid slippage of saddle and a potential fall from the animal.
Risks to Unborn Children
Because of the inherent risks of riding horses to the safety of unborn children, RRC advises pregnant women not to ride horses.
Note - No riders over 200 pounds.
Equine, etc. Activity Waiver & Photo Release
I am over 18 years of age. I acknowledge that Redeemed Ranch Camp is providing instruction and/or trail riding which I and/or my minor children as listed under
“Registration of Participants” wish to participate. I recognize and acknowledge that my/their participation in such activities and any other activities (which may or
not include equine activities), involves the possibility of inherent risks including, but not limited to, the following:
•
•
•
•
The propensity of an equine to behave in ways that may result in injury, death, or loss to persons
on or around the equine;
The unpredictability of an equine’s reaction to sounds, sudden movement, unfamiliar objects, persons,
or other animals;
Hazards, including, but not limited to, surface or subsurface conditions;
A collision with another equine, another animal, a person, or an object; The potential of an equine
activity participant to act in a negligent manner that may contribute to injury, death, or loss to the
person of the participant or to other persons, including, but not limited to, failing to maintain control
over an equine or failing to act within the ability of the participant.
With full knowledge of the above and any other inherent risks which may or may not be associated with equine activities, I hereby consent to our participation in
the above described activities, and I (on behalf of myself and/or my children/legal ward(s) agree to waive any and all claims for personal injury or property damage
of any kind which my children, I or my heirs, personal representatives and next of kin may have or which may arise against Redeemed Ranch Camp as a result of
my/their participation in such equine or any activities, whether or not such injuries or damages result from negligence or legal liability. On behalf of my children
herein listed, myself, my heirs, personal representatives and next of kin, I hereby release and discharge Redeemed Ranch Camp, its successors, assigns, affiliates,
directors, officers, employees and agents from any and all liabilities, claims, lawsuits, losses, costs, causes of action and damages of any kind originating or in any
way arising from my/their participation in such equine or any activities.
I hereby declare that the terms of this Waiver and Release have been completely read, are fully understood and are voluntarily accepted for the purpose
of my/my children’s participation in the activities described herein.
_______________________________________________________
Signature of Participant (over age 18) or Parent/Legal Guardian
____________
Date
Print parent/legal guardian name: ______________________________ Relationship____________________
Street Address: __________________________________________________________
City/State/Zip Code _________________________
Emergency Telephone #: _____________________