Form 1 Camp NewArk Registration Form (All prospective campers must complete this form including sponsors/workers) Camper Name: _______________________________________________________________ Church/City: _______________________________________________________________ Camp NewArk 389 County Road 4853 Newark, Texas 76071 817/489-3580 Instructions: Please print or type in INK. Do not leave anything blank! If your answer is “none” or “not applicable”, write that in the blank. Forms with missing information will not be accepted. Please, only one camper per form. Name (last) _______________________________(first)________________________________ Address ______________________________________________________________________ City ____________________State _________ Zip_______________ Phone _______________ Parent Cell Phone#___________________________Other Phone#________________________ School grade just completed __________ Gender M F Birthdate _____/____/_____ Age Now ________ Social Security # _______-______-_______ Person to notify in event of emergency: Name__________________________________ Daytime Phone # _______________________ Evening Phone#___________________________Their Relationship to you?________________ ___________________________________________________________________ PLEASE SUPPLY ALL OF THE FOLLOWING INFORMATION. DO NOT LEAVE ANY SPACES BLANK. (A copy of your insurance card may also be attached.) Medical Insurance__________________________________ Group #__________________ Policy # ________________________ Company’s Address______________________________ City _____________________ State __________ Zip _____________Phone________________ Physical Limitations ( Asthma, diabetes, allergies, etc.), and / or special instructions (Allergic to certain medications, food allergies, rare blood type, wears contacts, etc?) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Page Two Form 1 Camper’s NAME____________________________________________________________ List all medication you take on a regular basis and/ or any you bring with you to Camp NewArk: 1) ______________________________________ 2)_______________________________ Date of last Tetanus Shot ______________________ Medical & Surgical Student Waiver: To be completed by parent(s) or legal guardian(s) of student under 18 years of age, OR students over 18 must complete this waiver themselves. *Mandatory Signatures Below I, ______________________________________, parent and /or legal guardian of ______________________________, minor, hereby acknowledge that said minor is presently under my care, custody, and control. Therefore, I give my child, the said minor, my express permission to attend Camp NewArk between the dates of__________, and ____________. I further expressly grant my permission for my child, said minor, to participate in all activities of said camp. I have listed above said minor’s physical conditions or medical problems that may need attention, and all medications regularly used by said minor. In the event there arises an emergency necessitating medical or surgical attention, I hereby consent and give my permission to the Camp NewArk staff, Stoneplace Ministries, or its representatives, or the Camp Sponsors of the above stated dates, or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon said minor which may, in their sole discretion, be necessary under the circumstances. I also consent and give permission for my child, at his/her own discretion, to participate in counseling sessions while attending Camp NewArk. I do release, acquit, discharge, and covenant to hold harmless the Camp NewArk staff, Stoneplace Ministries, or its representatives, or the Camp Sponsors of the above dates, from any and all action, damages, or liabilities arising out of the treatment of any sickness or accident incurred by my said child during the above dates. I also give authority to Camp NewArk security staff, to inspect my child’s room and belongings while at the camp for the safety and protection of all CampNew Ark participants if unusual circumstances make such an inspection necessary. I understand and agree that any and all legal disputes that may arise as a result of my child’s stay at Camp NewArk during the above dates will have the local Wise County Court as the point of venue. I understand that Camp NewArk staff may choose to use my child’s photo for promotional purposes. I have read the Camp NewArk Policies & Procedures and understand that my child will be dismissed from camp and sent home at my expense if he/she does not adhere to the rules. *Parent/Guardian Signature_____________________________________ Date ____________ Phone (______) ________/__________ AND/OR the signature of student 18 or over in agreement with above waiver understanding that I am the person referred to as the “child”. Page 3 Form 1 STUDENT CONTRACT I am signing this contract committing myself to participate in the activities planned for this camp and endeavor to make this the best week of my life. I promise to conduct myself in a Christ-like manner, and have read the “Camp NewArk Policies & Procedures”. STUDENT SIGNATURE________________________________________________________ My T-shirt size is _____________ Adult: S, M, L, XL Child: S, M, L SPONSOR CONTRACT I agree to strive to reflect a Christ-like attitude while I serve as a sponsor. I realize that it is a privilege and responsibility to serve children and youth and will do my best to be an example to each person involved. I have read the Camp NewArk Policies & Procedures. SPONSOR SIGNATURE_______________________________________________________ My T-shirt size is __________ Adult: S, M, L, XL, XXL