Camper's First name

Camper's Last name

Gender

Male

Female

Have you attended camp before?

Yes

Camper's Age

Camper's Date of Birth:

Camper's Grade Level in 2024-25

Text #

Mailing Address

City

State

Zip Code

Parent/Guardian's First & Last Name:

Names of all people who have permission to pick your child up from camp:

1. Activity Release:

Knowing there are dangers, hazards, and risks associated with Pinerock Camp & Retreat Center’s activities including Archery, Climbing Wall, Low Ropes, High Ropes, Zip Line, Paintball, BB Guns, Swimming Pool, and/or related activities (hereafter “Activities”), and with sufficient knowledge of my experience, physical condition, and any and all limitations I may have at the time, I voluntarily assume all responsibility and risk of loss, damage, illness, injury and/or death that I may in any way sustain in connection with my voluntary participation in any and/or all of these Activities.

Understanding that I could be injured or die as a result of my participation in the Activities, I agree to release, indemnify and discharge Pinerock Camp & Retreat Center and their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (collectively “Pinerock”) and hold Pinerock harmless on behalf of myself, my children, my parents, my heirs, assignees, personal representative and estate.

It is my intent by signing this document to agree not to make a claim or bring a law suit against Pinerock or SIMC and to forever release them from any and all legal responsibility for any loss, injury, damage (including death) that I (or my camper) may suffer as a result of my participation in the aforementioned Activities whether due to negligence, default, action or inaction on the part of Pinerock or SIMC, with the exception of gross negligence on the part of Pinerock or SIMC.

Upon signing this form, I acknowledge and agree that I must abide by all rules, regulations, expectations, and standards of conduct applicable to participation in the Activities. I understand that Pinerock or SIMC reserves the right to limit or terminate my participation in any activity, in the sole discretion of Pinerock or SIMC staff.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT, WAIVER AND RELEASE AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Parent/Guardian's Signature

Today's Date

Photo/Media Release

As the Parent/Guardian, I give my consent to use my child’s photograph, likeness or image, whether in still frame, voice or video format by World Gospel Mission/American Indian Field/SIMC/Pinerock in publications, promotional brochures, video presentations, on the world wide web and in display formats.

I understand I am giving this permission with no financial compensation to me in return for the use of my child’s photograph, likeness or image, and release World Gospel Mission/American Indian Field/SIMC/Pinerock from any legal liability for the use of said photograph, likeness or image. I hereby give my permission to use my child’s photograph, likeness and image of my own free will.

Parent/Guardian's Signature

Today's Date

3. Transportation

Choose one:

I will be dropping off and picking up my child at the Christian Community Center (formerly known as the Southwest Indian Ministries Center) 14202 N 73rd Ave., Peoria, AZ 85381

I (or another adult) will be dropping off and picking up my child at Pinerock (1400 Pine Dr # 203., Prescott, AZ 86303)

I grant adults associated with SIMC to transport my camper for the purposes of camp and activities associated with camp.

Parent/Guardian's Signature

Today's Date

4. Medical Release

I/We [parent/guardian] give permission for (our) child [camper] to participate in the Pinerock and SIMC program and associated field trip(s). Should my/our child become injured, I/we request that the trip leader or designated Pinerock or SIMC staff secure emergency medical services to aid my/our child, if in their judgment such services are necessary. I/we agree to incur any additional expenses associated with such action. As parents/guardians, I/we have decided (with or without medical advice) that my/our child is physically, mentally, and socially able to participate, and I/we acknowledge that any medical or accident insurance we consider necessary will be my/our responsibility to locate and purchase. Furthermore, I/we have read all sections of this form and do hereby release Pinerock, SIMC, and its employees from liability for any damages, injuries, or losses which may occur while said child is participating in this Pinerock and SIMC program.

Parent/Guardian's Signature

Insurance company

Insurance Policy Number:

Insurance Group Number:

Today's Date

5. Medical Information & Permission to give medication

If there are known allergies, please list them below:

Please list and medical conditions or recent illnesses that we need to be aware of:

ALL MEDICATIONS MUST BE TURNED IN DURING REGISTRATION. Prescription Medications must be in the original container from the Pharmacy with the Dr.’s name and directions clearly visible on the label. Please list the Prescription and Over The Counter Medications your child has with him/her and needs to take during camp along with the instructions for giving them.

Name of Medication / Dosage and time to be taken / Reason for taking:

In addition to the medications listed above, I give permission for SIMC staff to give the following medications that I have marked to my child as needed, according to the appropriate age/weight dosing:

Cough Drops or Cough Syrup

Tylenol (for pain or fever)

Calamine Lotion for itch

Ibuprofen (for pain or fever)

Maalox for upset stomach

Antibiotic ointment for wound care/infection prevention

Parent/Guardian's Signature

Today's Date

Emergency Contact:

Relationship to camper:

Emergency Phone Number