Weekend Retreat 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

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Camper's Email *

Camper's Phone Number *

Retreat Session Selections *

Senior High Fall Retreat (Youth 9-12 grades) Wilderness Weekend Winter Bash (Youth 6-12 grades) Snow N' Glow (Youth 3-5 grades)

Gender *

Adult/Minor *

Birth Date *

Grade In The Fall *

Pick-up authorization *

Roommate Request *

Over The Counter Medication *ie tylenol, Benadryle... *

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 sprains, 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 *

Date *