Summer Registration Form

general registration & medical release form

Please note our forms are for adult and minor campers. Please fill out all required sessions as applicable for you.

* Indicates required field

Camper Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Camper's Email *

Camper's Phone Number *

Summer Camp Sessions *

Gender *

Adult/Minor *

Birth Date *

Grade In The Fall *

Pick-up authorization *

Roommate Request *

Over The Counter Medication *I.E. Tylenol, Benadryl... *

Allergies? If yes, please list in the box to the right. *

Yes No

Are You Allergic To Any Medications? If yes, please list in the box to the right. *

Yes No

Are You Currently On Any Medications? If yes, Please list in the box to the right. *

Yes No

List Serious Allergies *

List Medication Allergies *

List of Medications *

Have You had a seizure in the last 12 months? If yes, please list in the box to the right. *

Yes No

Do you have heart defects, disease or high blood pressure? If yes, please list in the box on the right. *

Yes No

Do you have debilitative back, knee or similar structural disorders? If yes, please list in the box on the right. *

Yes No

If yes please list the medication for this seizure condition *

Heart issue *

Structural Disorder *

Have you had any serious spraines, broken limbs or surgery of any kind in the last 12 months? If yes, please list in the box on the right *

Yes No

Are you or do you believe yourself to be pregnant? *

Yes No

Please list spraines, sugeries... *

Year of last tetanus shot *

Insurance Provider Name *

Policy # *

Physicians Name *

Physicians Phone Number *

AUTHORIZATION FOR tREATMENT/ eMERGENCY cARE

I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests and treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp executive director to secure and administer treatment, including hospitalization for the person named above. This complete form may be photo copied for trips out of camp. The health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities as noted.
I agree to release and hold harmless Koinonia Camp, its employees and volunteers from any and all claims including, but not limited to physical or property damage suffered by my child as a result of attending a camp or travel during camp. During travel, I understand that my child will be accompanied by a responsible adult and every precaution will be taken to safeguard the welfare of the campers.

Father's Name *

Mother's Name *

Family Email *

Father's Phone Number *

Mother's Phone Number *

Emergency Contact Name *

Emergency Contact Phone # *

Church's Name *

Church Phone # *

Physical Activity Release

Camp Activities include, but are not limited to hiking, swimming, low and high Koinonia Adventure course activities, canoeing, horseback riding, archery and paintball adventure games. There are risks of physical injury or harm from participating in high adventure activities. I voluntarily elect to participate in the activities and assume the risks of injury of harm that could result from participation. On my own behalf and that of my personal representatives and heirs, I hereby release Koinonia Camp its officers, employees, and agents from all liability for any injury or harm to me (or my minor) from participating in said activities; whether the injury or harm is caused by the negligence of Koinonia Camp or otherwise. I have read and understood this release of liability.
Participation in the physical aspects of any or all outdoor initiatives is absolutely voluntary. I acknowledge the fact that not all of the stresses and hazards connected with the activities can be foreseen. Some of the specific hazards I might encounter include slipping and falling on trails, bumps, bruises, cuts, scrapes, insect stings, poison ivy, sprains or other injuries. Facilitators will take every reasonable precaution to minimize exposure to known risks. I have the personal responsibility to follow all the safety rules and guidelines given to me. I hereby personally assume all risks in connection with the activities and I waive all claims arising out of the safety rules and guidelines given to me.

Activity Release *

Low Initiatives High Ropes Small Animal Experiences Paintball

*Please note that by registering your child for this camp you are giving Koinonia Camp permission to take and use pictures and videos for promotional purposes.*

Parent or Guardians Electronic Signature *

Equine release form

If your camper is eligible, would you like them to participate in Equine Activities? *

Yes - please fill out all the remaining boxes. Please note that if the form is not totally completed your student will not be eligible to participate. No

Date *

Participants Name *

First

Last

Parent or Guardian Name *

First

Last

Date *

By and between Koinonia Camp & Conference Center, hereinafter referred to as MANAGER, and the participant filling out this form hereinafter referred to as PARTICIPANT. For consideration received, and in return for the use today, and on all future dates of the property, facility and services of Manager, participants, participant’s heirs, assigns and representatives of, hereby agree as follow:
Inherent risk and Assumption of Risk. The undersigned acknowledges there are Inherent risks associated with equine activities. The inherent risks include but are not limited to, the propensity of equines to behave in ways such as running, bucking, kicking, biting, shying, rearing, falling or stepping on, that may result in injury, harm, or death to persons on or around them; the unpredictability of the equines reactions to things such as sounds, sudden movements and unfamiliar objects, persons or other animals; certain hazards such as surface and subsurface conditions; collisions with other animals; the limited availability of emergency medical assistance; and the potential of a participant to act in a negligent way that may contribute to injury to the participant or others, such as failing to maintain control over the animal, not acting within the participant’s ability, or not following instructions. Participant acknowledges that horses, by their very nature are unpredictable and subject to animal whims. Participant assumes all responsibility in connection there in, and expressly waives any claims for any injury of loss arising therefrom. Participant agrees to abide by and follow Manager’s rules and regulations which shall be stated, posted and/or available from time to time. Participant further acknowledges that the behavior of any animal is contingent to some extent upon the ability of the participant. Participant assumes all risks therefore and warrants a full and fair disclosure of the participant’s abilities has been made to manager.

Participant expressly releases manager from any and all claims for personal injury or property damage, even if caused by negligence on the part of the manager (if allowed by the laws of the state of Ohio) by manager, representatives or employees. Warning
Under Ohio law, an equine activity sponsor, equine activity participants, equine professional, veterinarian, farrier, or other person is not liable in damages in a tort or other civil action for harm that an equine activity participant allegedly sustains during an equine activity and that results from inherent risks associated with the activity pursuant to Ohio revised code annotated 2305.321 (2001)

Release of Liability Participant agrees to hold harmless, indemnify, and defend manager against, and hold harmless from, and all claims, demands, causes of action, damages, orders, judgments, costs or expenses, including attorney’s fees., whether actually incurred or not, which may in any way arise from or in any way be connected to the participants use of or presence upon the property of the manager or the facilities thereof.
In the event that the participant is using participants own horse(s), or a horse(s) not owned by manager, participant warrants said horse shall be free of infection, contagions or transmittable diseases. Manager reserves the right to refuse access of use of any horse upon the premises that does not appear to manager to be in good health, or is dangerous or in any way deemed undesirable by manager.
Any action brought under this agreement shall be brought within (1) year of the incident of accident giving rise to said claim. Participant agrees damages shall be limited to $250 in property damage, actual expenses incurred, and a maximum of $10,000 for damages such as pain and suffering.

Participant agrees to waive any applicable statutes in this jurisdiction whose purpose, substance and/or effect, is to provide that a general release shall not extend to claims, material or otherwise, which the person giving the release does not know or suspect to exist at the time of executing said release.

Signature of Rider or Parent/Guardian *

Please note that your child will not be eligible for any discounts until a registration and $20.00 deposit have both been submitted to our office. If you would like to pay your deposit online please follow the prompts on the next page.