HIGHLAND LAKES CAMP & CONFERENCE CENTER
BOYS AND GIRLS CAMP 2013
5902 Pace Bend Rd. North • Spicewood, TX 78669
888-222-3482 • 512-264-1777 • 512-264-2794 (Fax) • www.highlandlakescamp.org
MANDATORY ADULT REGISTRATION FORM INSTRUCTIONS: Individuals 19 years of age or older— Complete the Adult Registration
form in its entirety. All requested information is applicable. Type or print legibly in Dark Ink.
Adult’s Name: __________________________________________________________________________ First Middle Last (indicate name used)
Mailing Address: __________________________________________________________________________________________________________ Street Apt. # City State Zip
Birth Date: _____/_____/_____ Age Now :_____ Sex: (M/F) _____ T-Shirt (Adult Size):_____ Social Security No.:______________________ Mo. Day Year
Phone Number: Daytime: (_______)__________________ Evening: (_______)__________________ Other: (_______)____________________
Email: __________________________________ Occupation: ____________________________ Employer: ____________________________
Have you been convicted of a felony: YES NO If yes, explain: ______________________________________________________________
I have attended HLC Boys and Girls Camp before: YES NO
Name of Church or Group with whom you are attending: _______________________________ City: _________________________ State: ____
AGREEMENT TO ATTEND, PARTICIPATE, ASSUMPTION OF RISK AND LIABILITY WAIVER HIGHLAND LAKES BAPTIST ENCAMPMENT d/b/a HIGHLAND LAKES CAMP & CONFERENCE CENTER hereinafter referred to as the “Camp” requires a signature for all attendees of the Camp and all participants of any Camp activity including, but not limited to, Challenge/Ropes Course (highs and lows), Paint Ball, Water Crafts, Water Toys, Swimming Pool, Bicycle Course, Backpacking, Camping, Basketball, Football, Baseball, Softball, Volleyball, and any and all other camp and recreational sports and activities. Furthermore this form releases the Camp to photograph and/or use photographs of myself or my child for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and activities of Camp. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to attend Camp and to participate in any Camp activity.
Attendance and Activities at Camp may include warms-ups, games, group initiative problems, high and low challenge course, paint ball and/or other rigorous physical adventure activities as well as exposure to the elements, exposure to animals, snakes and insects. Camp takes all reasonable precautions to ensure you a safe and enjoyable experience. Parts of the experience, by their nature, can be physically demanding and include varying levels of stress and anxiety, not all of which can be foreseen. The decision to attend the Camp and the decision to participate in any Camp activity at any level IS AT ALL TIMES COMPLETELY UP TO THE INDIVIDUAL’S CHOICE and, if there is attendance at the Camp and participation at any level of any Camp activity, there is a risk, which must be assumed by each attendee and by each participant. Although it is the Camp’s goal to maintain the physical, emotional and social safety of each attendee and participant of the Camp, the physical, emotional and social risks must be assumed by each attendee and participant.
“I understand that attendance at the Camp and participation in any Camp activity may be physically and emotionally demanding. I recognize the inherent risk of physical and/or emotional injury of attending Camp and participating in any and/or all Camp activities. I understand that each participant must assume the risk of any injury, physical and/or emotional, and any financial responsibility that could result from attending Camp and participating in any Camp Activity. I agree to assume such risks and such responsibility. I, on my behalf, and on behalf of my heirs and assigns, hereby release, indemnify and hold harmless Highland Lakes Baptist Encampment d/b/a Highland Lakes Camp and Conference Center from any and all claims, physical and emotional, including bodily injury, that I may have that may be sustained in connection with my attending Camp and with my participation in any and/or all Camp activities.”
If you feel that there are any activities in which you or your child should not be involved in, please describe for us on an attached sheet the activities (include name and church/group name on the attached sheet). I understand the directors of Highland Lakes Baptist Encampment reserve the right to dismiss, without refund, any camper whose influence is detrimental to the operation of the camp, as determined by the discretion of the directors. I understand that the use of alcohol, tobacco products, and illegal drugs is strictly prohibited at all Highland Lakes Baptist Encampment programs.
I have read the Camp rules and agree to abide by all established regulations. I further understand that if I disregard the Camp rules that I will be dismissed and sent home at my own expense. I understand that I will be held financially responsible for any property damage I might cause.
I have read (or had read to me) this complete document and I understand the information contained herein. I have freely and voluntarily signed this document. I authorize my son/daughter to participate in all camp activities, unless written notification attached specifies otherwise.
X ____________________________________ __ ______ Required Adult Attendee/Participant Signature Date IMPORTANT. THIS IS PAGE 1 of 3 see reverse for GENERAL CAMP RULES ADULT REGISTRATION FORM / GENERAL CAMP RULES
All medications are to be listed on the Registration/Medical Release form, registered with the HLC medical staff and taken to the Health Center. All medications must be in original bottle and/or container. Medications will be administered as per RX label instructions and dosage, unless written, signed, and dated parental instructions state otherwise. A completed Medication Administration Form should be provided with the medications. Guests are not to share any medications, including over-the-counter medications.
Guests who are ill or injured must be either in the HLC camp office, medical clinic, or hospital. In the event of illness or injury, students will not be permitted to remain in their dorm rooms.
Prank supplies are not allowed in the dorms (i.e. shaving cream, body paint, water balloons, water guns/blasters). There are no exceptions.
Adult supervision is required at the lake and/or pool. At no time is a student to go to the lake and/or pool without adult supervision. Lifejackets are required for lakefront activities, regardless of a person’s age or water safety ability.
Drugs, alcohol, any form of tobacco, firearms, knives, or any kind of weapon, matches or fireworks are NOT allowed.
Guest should not bring the following to camp: Cell phones, iPods, mp3 players, video games, CD players, television, laptop computer, play station or any other type of electronic games or equipment should not be brought to camp. Keepsake or valuable jewelry, collectible or memorabilia sportswear should not be brought to camp. HLC will not be responsible for the misplacing or theft of guest personal property.
Skateboards, rollerblades, Heely roller shoes are not allowed.
Guests are discouraged from bringing food items. Snacks will attract ants in the dorms. We suggest that if you bring snacks, that the food be stored in tightly sealed containers, such as a plastic storage container or zip-lock plastic bag. No electric appliances to be used for food preparation is allowed. The HLC Concession stand will be open throughout the day and each evening.
Guests (students and adults) are expected to reflect a Christian example by their dress. Sponsors, parents, and church leaders are responsible for the clothing and appearance of the youth and adults attending camp. The manner of dress should be set and clearly communicated prior to leaving home. Modest skirts, dresses, shorts, and jeans are acceptable in worship. Immodest short shorts or tops, small tank tops, tight clothes, spaghetti strap tops, distasteful designs or messages, cheer shorts and other extreme clothes are not acceptable at any time. Shorts must be longer than the arm and hand when extended down the side of the person. One-piece swimsuits are preferred. All others will require a dark colored t-shirt to be worn over them at all times, including while in the water. Campers may be asked to change their attire if an adult or HLCCC staff feels their dress is inappropriate.
10. Refrain from Public Display of Affection with others.
11. Under NO circumstances are girls to be in guys rooms or guys in girls rooms.
12. No fighting or inappropriate / profane language is allowed.
13. Students are to respect all adult leaders and follow their instructions. All adults–members of HLC leadership team, church leadership teams, and
adult volunteers–are in places of authority over all students. They have been trained in how to guide students for each particular event.
14. Everyone must attend all scheduled events. If your group is in an activity, whether in the classroom or on the athletic field, you must be with
them. There are no exceptions to this unless you are injured or sick and are at the HLC Health Center, doctor’s office or hospital.
15. Guest MUST be in the dorm by designated camp curfew. Your curfew is for your security and for your mental and physical well-being.
16. Guest must wear nametags at all times. Each Boys and Girls Camp participant will be issued a nametag upon arrival, which is to be worn during
all meals, and other activities during the day. Nametags are required at the Health Center before a camper can be given medical attention.
17. Guests are not allowed to leave Highland Lakes Camp without proper parental written authorization and approval of HLC administrative staff.
18. Guests are not allowed to bring pets on campus. No pets in the dorms, motels, or meeting rooms.
19. Guest and/or church group leadership will be held financially responsible for any property damages that occur during their stay at HLC. Campers
should refrain from writing on furniture or walls. Do not use duct tape to affix signs to doors or walls.
20. For your safety, guests are not allowed on any HLC “RESTRICTED” property areas.
MANDATORY ADULT MEDICAL RELEASE FORM
In the event of an accident or special health needs, it will be necessary for us to have the requested information. Please make certain that you have
provided thorough and accurate medical information. It is recommended that you attach a photocopy of your family medical insurance card.
Name of Adult Sponsor: _________________________________________________ Birth Date: _____/_____/_____ Age: ___Sex: (M/F) _____ First Middle Last Mo. Day Year
Church: ________________________________________________ City: _____________ Dates at HLC: _____/____/____ to _____/____/____
Person to Notify in Event of Emergency: ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________
If unable to reach above person: Notify ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________
Family Physician: _________________________________________________ Phone: (_______) ______________________________
Medical Insurance Co.: ____________________________________________ Plan or Group #: ________________________________
Insured ID or Member #: ___________________________________________ Ins. Co. Phone #: (_______)_______________________
Diseases, Chronic or Recurring Illness: (Check all that apply, explain)
Bleeding Disorder: ____________________________________
Insect Sting: __________________________________________
Dermatological Condition: ______________________________
Ear Infections: _________________________________________
Heart Defect: __________________________________________
Special Diet: ____________________________________________
Stomach Condition: _____________________________________
Recent Surgery? _________________________________________
Date of last Tetanus Shot? ______ Immunizations Current? ______State law requires all medications to be placed in the campus Health Center. All medications must be brought in the original container (prescription or over-the counter) properly labeled as prescribed by law. Prescription labels must have the camper’s name and current dosage. A current Medication Administration Authorization Form MUST accompany all medication. Medications and Administration instructions will be collected and reviewed by HLC Medical staff upon camper arrival. HLC Medical staff requests that you NOT send over the counter medications such as Tylenol, Ibuprofen, Benadryl or antihistamines. HLC stock an assortment of over the counter medications for the occasional need. HEALTH CARE AND CAMP PERMISSION— INITIAL & SIGN THE STATEMENTS BELOW. ___ I give my permission for first aid techniques and simple health care to be administered as the need arises. I understand in the event of any serious injury or illness on my part the camp officials reserve the right to seek professional medical attention including but not limited to consultation with medical director, EMS transportation, and hospitalization. ___ I give permission for myself in consultation with the Camp Health Supervisor and/or the medical director’s standing orders to take the following medications as indicated by checking below:
___antihistamine (i.e. Benadryl, Claritin)
___additional medications as indicated/prescribed by the HLC Medical Director
I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that I am in acceptable heath, physical ability, and emotionally ready to fully participate in camp. I grant my permission to participate in all activities associated with the enrolled event with the exceptions of those that are noted.
I, _______________________________ give my permission to Highland Lakes Camp and Conference Center’s management, medical staff, and/or the group director to provide medical treatment that may be deemed necessary to insure my well-being. I, the undersigned, do hereby release and forever discharge all from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in Highland Lakes Camp sponsored activities.
X ___________________________________________________ ____/____/____ (_______) ____________________________ Adult Sponsor/Leader Signature Date Phone Number
Is it safe for pregnant women to use NRT? Lifestyle (avoiding people, places and things that trigger smoking) and behaviour changes (delaying and distractingtechniques) are recommended ﬁrst before considering NRT. If you are unable to quit, try NRT aer the ﬁrst trimester(3 months). If you are pregnant or breastfeeding, always check with your doctor before using any medications; thi
R. Mennes, voorzitter (burgemeester) G. Rottiers, N. Moortgat, K. Van Hoofstat, schepenen A. Ams, G. Van Frausem, L. Haucourt, D. Backeljauw, V. Goris, J. Van Wijnsberghe, R. Jacobs, R. Wilms, P. Van Bellingen, S. Billiau, F. Sleeubus, R. De Clerck, raadsleden K. Moulaert, secretaris A. Boen, schepen van rechtswege I. Barbier, D. Bollé, L. Van der Auwera, raadsleden OpeGelet op artikels 117, 11