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:

Chapel Rock programs involve a variety of activities that often include warm-ups, games, group initiative problems, high and low ropes course elements, rock climbing, rappelling, kayaking, orienteering, and other rigorous physical adventure activities. (The level of participation in a program activity is at all times completely up to the individual Trained professional staff conducts all programs; yet there is a risk which must be assumed by each participant that he/she may suffer an emotional or physical injury, disability or death. Every participant in Chapel Rock programs is encouraged to have health/accident insurance coverage. In addition, certain health/medical information must be made known to the instructor(s) conducting programs, so that they are prepared to respond appropriately if the need arises. This information will be held in confidence. High ropes activities have a weight minimum of 45lb and a maximum of 275lb, and by participating in our high ropes you acknowledge that you are between these.

Do you have any limiting physical or mental disabilities or medical restrictions (temporary or permanent) that could hazard yourself or others during the duration of this program? If yes, identify and explain…

If you selected Yes above, please explain:

Do you have any allergies, reactions to medication, or any other medical limitations? If yes, identify and explain:

Yes

If you selected Yes, please explain:

Have there been any recent or major life changes? (E.g. Job changes, death in family, etc.)

Yes

If you selected Yes, please explain:

I understand that parts of the Chapel Rock and SIMC program may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician's care for any undisclosed condition that bears upon my fitness to participate in Chapel Rock and SIMC activities. I understand that each participant must assume the risk of physical injury that could result from any of these activities. I release Chapel Rock, SIMC, and its staff members, from all liability for any injury to me from participation in Chapel Rock and SIMC activities.

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/Chapel Rock 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/Chapel Rock 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 ChapelRock (1131 Country Club Dr., 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 Chapel Rock and SIMC program and associated field trip(s). Should my/our child become injured, I/we request that the trip leader or designated Chapel Rock 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 Chapel Rock, SIMC, and its employees from liability for any damages, injuries, or losses which may occur while said child is participating in this Chapel Rock 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 Phone Number