DEADLINE May 22 - Timberline Church€¦ · the hot spring and riverside yurt camping. Noah’s Ark...

2
REGISTRATION FORM/MEDICAL RELEASE Middle School Summer 2016 (Once registered, Noah’s Ark forms will be emailed to you) Student Name _________________________________ M F Date of Birth _________ Grade just completed _____ Student Cell __________________ Student Email _______________________________________ Campus Fort Collins Windsor Other Parent/Guardian _______________________________ Phone_______________ Address _________________________________City _________________________Zip________ Parent Email________________________________________________________________ Add me to the Parent Newsletter Y___ N____ Name of Insurance Company________________________________________________ Policy #_________________________________ Physician’s Name_________________________________________ Phone______________________ ALLERGIES OR PERTINENT INFORMATION: Please list any medical allergies, food allergies, medications being taken, medical prob- lems or other pertinent information. You may be asked to provide a copy of the insurance card and the prescription card if applicable. _________________________________________________________________________________________________________ I understand that in the event that medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to the adult sponsors of Timberline Church to secure the services of a li- censed physician, to provide the care necessary, including anesthesia, for my student’s well- being. WAIVER OF LIABILITY STATEMENT I, the parent or legal guardian of the student listed above, release adults in charge from any and all claims resulting from injury or damage that may be sustained by my student while participat- ing in any/all activities. Any pictures taken of my child may be used for promotional uses within the Church. By signing this I agree to all the above statements and give permission for my stu- dent to attend TIMBERLINE MIDDLE SCHOOL ADVENTURE CAMP 2016 and participate in all planned activities. Parent/ Guardian Signature_________________________________________________________________Date:______________ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Keep this half Payment Details: Check #________ Cash____ Online____ Donation for Scholarships $__________ Total Attached $__________ JUNE 4-7, 2016 Grades 6-8 Spring 2016 COST Includes transportation, lodging, meals, rock climbing, the Hot Springs, and Aerial Adventure Park DEADLINE May 22 This form and $100 non-refundable deposit are required to complete your registration. Final payment due May 31. Register Online: www.timberlinechurch.org/middleschool Register at Timberline Church: TSM Middle School or Fort Collins office. DETAILS Parent Meeting May 25 6-7 in the Timberline Student Center After you register, look for emails that will include: Packing List Check-in Time Detailed Schedule Noah’s Ark Permission Forms EMERGENCY CONTACT During the trip: Noah’s Ark 719-395-2158 Justin Matthews 970.207.6136 Turn in this portion only

Transcript of DEADLINE May 22 - Timberline Church€¦ · the hot spring and riverside yurt camping. Noah’s Ark...

Page 1: DEADLINE May 22 - Timberline Church€¦ · the hot spring and riverside yurt camping. Noah’s Ark is the premiere guid-ing and rafting company in Colorado, with a long history of

R

EGIS

TRA

TIO

N F

OR

M/M

EDIC

AL

REL

EASE

Mid

dle

Sch

oo

l Su

mm

er

20

16

(On

ce

re

gis

tere

d,

No

ah

’s A

rk f

orm

s w

ill b

e e

ma

ile

d t

o y

ou

)

Stu

de

nt N

am

e _

__

__

__

___

___

__

___

___

__

__

___

__

__

_

M

F

Date

of

Bir

th _

__

___

___

Gra

de

ju

st com

ple

ted _

___

_

Stu

de

nt C

ell

__

__

___

__

__

____

__

_ S

tude

nt

Em

ail

___

___

__

__

___

___

__

__

___

__

__

___

__

__

___

__

Cam

pus

Fo

rt C

olli

ns

Win

dso

r O

the

r

Pa

ren

t/G

ua

rdia

n _

__

__

__

____

__

___

___

__

__

___

__

__

_ P

ho

ne

___

___

__

__

___

__

Ad

dre

ss _

__

___

___

__

__

___

__

__

___

___

__

__

___

City _

____

__

___

___

__

__

___

__

__

_Z

ip__

__

___

_

Pa

ren

t E

ma

il__

__

___

__

__

____

__

___

___

__

__

___

__

__

___

__

__

___

___

__

__

___

__

__

___

__

_ A

dd

me

to

the

Pa

ren

t N

ew

sle

tte

r Y

__

_ N

__

__

Nam

e o

f In

su

ran

ce

Co

mpa

ny__

__

___

___

__

__

___

__

__

___

__

__

___

___

__

__

___

__

__

___

Po

licy #

__

__

__

__

___

__

__

____

__

___

___

__

__

__

Ph

ysic

ian

’s N

am

e_

__

___

__

___

__

___

___

__

__

___

__

__

___

__

__

___

_ P

ho

ne_

__

__

___

__

__

__

___

___

__

AL

LE

RG

IES

OR

PE

RT

INE

NT

IN

FO

RM

AT

ION

: P

lea

se

lis

t a

ny m

ed

ica

l a

lle

rgie

s,

foo

d a

lle

rgie

s, m

ed

ica

tio

ns

be

ing

ta

ke

n, m

ed

ica

l p

rob

-le

ms o

r

oth

er

pe

rtin

en

t in

form

atio

n.

Yo

u m

ay b

e a

ske

d t

o p

rovid

e a

co

py o

f th

e insu

ran

ce

ca

rd a

nd

th

e p

rescri

ptio

n c

ard

if a

pp

licab

le.

__

__

__

___

__

__

___

__

__

___

__

__

___

___

__

__

___

__

__

___

__

__

___

___

__

__

___

__

__

___

__

__

___

___

__

__

___

__

__

___

__

__

___

___

I u

nd

ers

tan

d th

at in

the

eve

nt th

at

me

dic

al tr

eatm

en

t is

req

uire

d,

eve

ry e

ffo

rt w

ill b

e m

ad

e to c

on

tact m

e. H

ow

eve

r, if

I ca

nn

ot

be r

each

ed

, I

giv

e m

y p

erm

issio

n to

the

adu

lt s

pon

so

rs o

f T

imb

erlin

e C

hu

rch

to

se

cu

re th

e s

erv

ices o

f a

li-

ce

nse

d p

hysic

ian

, to

pro

vid

e th

e c

are

ne

cessa

ry,

inclu

din

g a

ne

sth

esia

, fo

r m

y s

tude

nt’s w

ell-

be

ing.

WA

IVE

R O

F L

IAB

ILIT

Y S

TA

TE

ME

NT

I, t

he

pa

ren

t o

r le

ga

l gu

ard

ian

of

the

stu

de

nt lis

ted

abo

ve

, re

lea

se a

dults in

ch

arg

e f

rom

any a

nd

a

ll cla

ims r

esu

ltin

g fro

m inju

ry o

r d

am

ag

e t

ha

t m

ay b

e s

usta

ine

d b

y m

y s

tude

nt

wh

ile p

art

icip

at-

ing

in

an

y/a

ll activitie

s.

An

y p

ictu

res ta

ke

n o

f m

y c

hild

ma

y b

e u

sed

fo

r p

rom

otion

al u

se

s w

ith

in

the

Ch

urc

h.

By s

ignin

g t

his

I a

gre

e t

o a

ll th

e a

bo

ve

sta

tem

ents

and

giv

e p

erm

issio

n f

or

my s

tu-

de

nt

to a

tte

nd

TIM

BE

RLIN

E M

IDD

LE

SC

HO

OL

AD

VE

NT

UR

E C

AM

P 2

01

6 a

nd

part

icip

ate

in

all

pla

nne

d a

ctivitie

s.

Pa

ren

t/ G

ua

rdia

n

Sig

na

ture

__

__

__

___

__

__

___

__

__

___

__

__

___

___

__

__

___

__

__

___

__

__

___

___

__

__

___

_D

ate

:__

__

__

___

___

__

---

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

--

Kee

p t

his

ha

lf

Pa

ym

en

t D

eta

ils:

Che

ck #

___

___

__

Cash

__

__

On

line

__

__

Don

ation

fo

r S

cho

lars

hip

s

$_

__

___

___

_

To

tal A

tta

ch

ed

$_

__

___

___

_

JUNE 4-7, 2016 Grades 6-8 Spring 2016

COST Includes transportation, lodging, meals, rock climbing, the Hot Springs,

and Aerial Adventure Park

DEADLINE May 22 This form and $100 non-refundable deposit are required to complete

your registration. Final payment due May 31.

Register Online: www.timberlinechurch.org/middleschool Register at Timberline Church:

TSM Middle School or Fort Collins office.

DETAILS Parent Meeting May 25 6-7 in the Timberline Student Center

After you register, look for emails that will include: Packing List Check-in Time Detailed Schedule Noah’s Ark Permission Forms

EMERGENCY CONTACT During the trip: Noah’s Ark 719-395-2158

Justin Matthews 970.207.6136

Tu

rn i

n t

his

po

rtio

n o

nly

Page 2: DEADLINE May 22 - Timberline Church€¦ · the hot spring and riverside yurt camping. Noah’s Ark is the premiere guid-ing and rafting company in Colorado, with a long history of

WHAT IS ADVENTURE CAMP? Four days of adventure and fun in the Collegiate Peaks wilderness at the Noah’s Ark Base Camp with your friends and TSM leaders. Activities will include, a High Ropes Adventure Park, rock climbing, a trip to the hot spring and riverside yurt camping. Noah’s Ark is the premiere guid-ing and rafting company in Colorado, with a long history of providing expert and safe adventure experiences centered around Jesus. Adventure, friendships, growing in your faith. It’s the perfect combination for summer.

SCHEDULE 6/4: Check-in, Timberline Church, head to Noah’s Ark. 6/5-6: Early breakfast, all-day activities, including swimming, ropes course, and rock climbing. Evening includes dinner, campfires, games, devotional and small group breakout times. 6/7: Return to Timberline Church. A more detailed schedule will be provided at registration

DONATE TO THE SCHOLARSHIP FUND Help another student have the opportunity to go to camp so they can learn and grow in Christ. All gifts will be handled by TSM and given to students as needed. List your amount on the registration form for tax credit.

970.482.4387 x121 [email protected] 2908 S. Timberline Rd, Fort Collins, CO 80525