CFC YOUTH – DALLAS
YOUTH CAMP REGISTRATION FORM
November 6-8, 2009
Mt. Lebanon Retreat and Conference Center
1701 Texas Plume Road, Cedar Hill, Texas 75104
$ 75.00 includes all camp materials, snacks and meals
Registration Due Date: October 31, 2009
These
forms must be both reviewed and understood
carefully by all concerned. Please sign, date and return (or mail,
address on
next page) to a Parent Coordinator or Camp leader on or before the due
date.
Dear Parent(s) or
Guardian(s):
Your child’s good
health,
physical, and emotional welfare is of prime importance and interest to
us while
he/she is attending the Youth Camp. Since it may be difficult to
contact
you right away in case of an emergency, we ask that you complete the
medical
information questionnaire and waiver/medical form as accurately as
possible to
help assure that your child will receive prompt and specific medical
attention
in the event of an emergency.
Name of Participant: ________________________________________________ Age: _______
Participants e-mail: _______________________ Date of Birth: __________________________
Address: ______________________________________________________________________
Home phone: ________________________ Parent’s Cell phone: ________________________
Parent / Guardian name: _________________________________________________________
Family Doctor: ______________________________ Phone number: _____________________
Medications currently being taken or required: ________________________________________
Medications the participant may be allergic to: ________________________________________
Medical condition currently being treated for: ________________________________________
Items allergic to or gets a reaction from (if any): ______________________________________
Restrictions of physical activities that applies to Participant: _____________________________
Our signatures certify that all the above information is true and correct.
____________________________________ ____________________________________
Signature of Participant Date Signature of Parent/Guardian Date
Please make checks payable to: COUPLES
FOR CHRIST (CFC)
Mail this form and check to: Johnny and Fe Poquiz
1705 Skyline Drive, Garland, Texas 75043
Registration and check-in on Friday, November 6:
Starts at 6:00 pm. First Session starts at 8pm.
What to Bring:
Sleeping bag or bed sheet, blanket, pillow, clothes appropriate for the weather, toothbrush, toothpaste, soap, shampoo, towel, pen and paper.
If your child is taking medication(s), please put these in a clear ziplock bag with his/her name on it and give to Parent Coordinators Vangie Sabado and Maritess Bonifacio for safe-keeping.
Parents are highly encouraged to come on Sunday morning to participate in a forum, have a wonderful private dialogue with their son/daughter and fellowship with other families. You may bring your favorite dish to share, if you desire. You will be called to confirm the time.
Parent Coordinators:
Johnny and Fe Poquiz 469-360-5036
Bonnie and Marites Bonifacio 469-767-0475
Globen and Vangie Sabado 469-235-8821
Direction to Mt. Lebanon Retreat and Conference Center:
From Dallas – Take I-20 W towards Fort Worth; take the ramp to US-67 S towards Cleburne and drive about 8 miles; take the Mt. Lebanon exit; turn right on Mt. Lebanon Road; drive about 0.70 miles; turn right on Texas Plume Road. The camp will be on your right after 0.20 miles.
(KEEP THIS PAGE FOR YOUR REFERENCE)
WAIVER AND MEDICAL FORM
All participants, read and sign this form
completely. If below 18, have
parents/guardian sign.
I, the undersigned parent and/or guardian of the child, whose name appears below (hereafter know as “participant”, hereby give my consent to attend the Youth Camp to be held at
Mt. Lebanon Retreat and Conference Center, Cedar Hill, Texas.
I understand that the above facility is covered by its own premise and general liability insurance policy. In the event of any injury to the participant, this document fully release CFC-Youth and all its members from any of the liability and/or responsibility which are not covered under the policy held by the mentioned facility.
I understand that my child will be provided constant adult supervision. My child, as a participant, will be able to follow directions, guidance and instructions in a proper manner at all times. By signing below, I am certifying that my child is responsible and willingly accepts rules and regulations.
I hereby authorize CFC-Youth to arrange for my child’s medical attention, diagnosis, treatment and hospitalization and care in case of an emergency, after an unsuccessful effort has been made to contact me.
I further hereby authorize and accept financial responsibility for any necessary first-aid, medical and surgical treatment to be performed by a medical facility, including 911 emergency call, for any injury or illness to my child occurring in any CFC-Youth sponsored activity, after reasonable effort has been made to contact me.
CFC-Youth is therefore fully absolved and released from any responsibility and/or liability for my child while engaged in any of the activities within the scope of the camp programs. I agree and understand that I hold CFC-Youth harmless from all liabilities, costs, damages to any property caused by or arising out of my child’s participation in the camp.
Name of Participant: ____________________________________
Signature: ________________________ Date _____________
Name of Parent/Guardian: _______________________________
Signature: ________________________ Date ____________