Event Registration

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2019 Camp United - High School & Super Seniors on Thursday, June 13, 2019

Free! 
Free! 
Welcome to Camp United registration! Instead of three separate forms, there is one form that includes the application, the EastLake Church Medical Treatment and Liability Waiver as well as information required by the Pinecrest Christian Conference Center.  You will fill this out for each child being registered. 

After filling out the form, you will have the option to pay a $100.00 deposit or full payment per child.  If paying the deposit, you will receive an email at the email address you enter on the payment page, with a link that you will use to make the final payment. Final payments are due by May 11th to secure your child's spot. Payments will be refundable due to extenuating circumstances until May 24th. After which, all payments are non-refundable.  
STUDENT INFORMATION
*Students Date of Birth (ex 01/01/2004):
*Gender:
*Grade Level NEXT School Year
*Which Network Church does the student normally attend?:
If you could share a cabin with a friend who would that be?:
*Growth Group Leader (If unknown, put N/A):
*Allergies (drugs, foods, ect.) If none, put N/A.:
*Special Needs or Medication:
Please explain special needs and medication:
*T-Shirt Size (Adult Sizes):
PARENT INFORMATION
*Parent/Guardian Names:
*Parent/Guardian Phone #(s):
*Parent/Guardian Email Address(es):
*Emergency Contact:
*Emergency Contact Phone:
ELC NETWORK PARENT/GUARDIAN CONSENT AND AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT AND WAIVER OF LIABILITY
I am the parent or legal guardian of the minor I am registering for this event.  I have been informed of Camp United sponsored by EastLake Church to take place at the Pinecrest Bible Conference Center in Big Bear California, and I hereby give my consent for my minor child to participate in this activity. 
*I understand all reasonable safety precautions will be taken by the leaders of this activity, and I acknowledge that the possibility of an unforeseen hazard does exist.  It is my intention to exempt and relieve EastLake Church, its leaders, employees, agents and/or volunteer staff [hereafter collectively referred to as "Activity Leader"] from any liability for personal injury or property damage to my minor child as may be caused by any act of negligence by the Activity Leader. In consideration of the Activity Leader organizing, arranging and  permitting my minor child to attend and participate in the event  described above and any related activity, the undersigned on behalf of  myself, my child and my heirs hereby knowingly, voluntarily and  absolutely releases, discharges, waives and relinquishes all such losses  as identified herein resulting from or arising in connection with my  minor child's travel to, attendance at or participation in this event or  any related activity. I also agree that in the event any claim is made for personal injury or  property damage as brought against the Activity Leader, the undersigned  will indemnify and hold harmless the Activity Leader from all such  claims and/or causes of action. I acknowledge that no promises, representations or affirmations of fact  were made to me by the Activity Leader concerning the safety of the  event or related activity, the security precautions taken in sponsoring  the event, the relative danger or safety associated with traveling to  the event or participating in any activity or outing related to, or  connected in any way to the event.:
*By checking the box, I acknowledge that I have read and understand the provisions releasing all claims on behalf of my minor child that I may have and I accept their terms as a condition to my child's attendance at this event and any related activity. :
*I hereby request and understand that my minor child is to be excluded from the following activities [if none, write "none"]
*In addition, I hereby do consent to any x-ray, anesthetic, medical, surgical or dental examination, diagnosis or treatment and hospital care that may be deemed reasonably necessary for my minor child under the general or special supervision and upon the advice of or to be rendered by any physician, surgeon or dentist. Further, I understand all reasonable efforts will be made to contact me  prior to treatment being rendered to my minor child.  In the event I  cannot be reached in an emergency, I give permission to the Activity  Leader to make those decisions necessary for treatment under Section  6901, 6902, and 6910 of the Family Code of the State of California,  U.S.A.  Should there be Activity Leader available, I hereby give my  permission to the attending physician or the attending dentist to treat  my minor child. I further understand that the doctors, dentists and  other providers attending with my child will take all reasonable safety  precautions during their care. Further, as the parent or legal guardian of the minor child named above,  I am responsible for the health care decisions for my minor child and I  am authorized to consent to services as set out above. I agree to pay  for all charges incurred on behalf of my child for medical or dental  treatment or hospital care. I represent that my consent to, and  agreement to pay for, the dental, medical or hospital care or treatment  to be rendered to my child is legally sufficient and no consent from any  other person is required by low. I also authorize the Activity Leader to receive physical custody of my minor child under Section 1283 of the State of California Health and Safety Code upon completion of any treatment and I specifically instruct any treating health facility to surrender physical custody of my child to the Activity Leader.  It is understood this authorization is given in advance of any special diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of the Activity Leader in the exercise of his or her best judgement, upon advice of the above referenced physician, surgeon and dentist.  :
THE INFORMATION BELOW IS REQUIRED BY PINECREST CHRISTIAN CONFERENCE CENTER
CAMPER REGISTRATION
Date attending camp will be June 13 - 17, 2019
The church name is EastLake Church Network.
The Church phone number is 619-421-4100.
*Name of Camper:
*Camper's Gender:
*Address:
*Home Phone Number (If not applicable, type N/A):
*Parent Cell Phone Number:
*Email Address:
*Parent or Guardian:
*School Attending:
*Grade for next school year:
*School District:
CAMPER'S HEALTH INFORMATION
*Name of Primary Medical Insurance:
*Policy #:
*Physician's Name:
*Physician's Phone Number:
*Does camper have any allergies you would like us aware of?:
*Does camper have any disease you would like us aware of?:
Does camper have any dietary modifications?:
*Does camper have up to date immunizations?:
*Date of last Tetanus shot:
*Does camper have any medical issues you would like us aware of?:
Check ALL applicable conditions
  
 
  
 
 
 
  
 
 
 
 
 
  
 
 
 
*Recent broken bones or other injuries:
If yes, the date and type of injury and activity restrictions:
*Recent Surgery:
If yes, date and type of surgery and any activity restrictions.:
*Vegetarian? I understand that if my child has a special dietary need I will provide the necessary food and the camp will provide refrigeration and access to the kitchen.
*History of Sleep walking:
Diabetic:
Non-Prescription Medical Available at Pinecrest
The medications listed below are kept in stock; do not feel obligated to send any of these items.  Please select a drop-down below to indicate your permission for the listed medication to be administered by your Groups Nurse or an authorized staff member.  We will not administer any medication without your authorization.
*Benedryl (itch, insect bite, sinus)
*Caladryl Lotion (poison oak)
*Mylanta/Tums (upset stomach)
*Robitussin (cough)
*Claritin (allergies)
*Pepto Bismol (diarrhea)
*Hydrocortisone Cream (itch/rash)
*Polysporin Topical (minor cuts/burn)
*Betadine (disinfectant)
*Non-Psuedo (sinus)
*Tylenol (head/muscle aches/cramps)
*Cough Drops (cough)
*Milk of Magnesia (constipation)
*Ibuprofin (pain reliever, fever reducer)
Prescription for Minors: (including Asthma/ADD/insulin/Epi-kit) any prescribed medicine or inhaler must be given the sponsoring organization for the camper's use under supervision. All medications must be sent in their original prescription container.
*Are you sending prescription or non prescription medication with your child?
If yes, please list and detail dosage information:
*Authorization for Medical treatment - ('I Agree' box must be checked or Camper cannot be treated) The undersigned do hereby authorize Mangers or Pinecrest LLC and/or Church/group listed as agent for the undersigned, to consent to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care for myself or listed family member, which is deemed advisable by the rendered under the general or special supervision of any physician or surgeon licensed under the provision of the Medicine Practice Act or any dentist licensed  under the dental Practice act, at a hospital or elsewhere.  The above mentioned agent is authorized to make decisions concerning the health and general welfare of myself or listed family member.  I give permission to the medical personnel selected by Pinecrest to provide routine health care, to administer medications, to release any records necessary for insurance purposes:  and to provide or arrange necessary transportation for myself or listed family member for the duration of the stay at Pinecrest. :
*Physical Activity Release:  Pinecrest activities include, but are not limited to, hiking swimming, basketball, volleyball, soccer, archery, skateboard park, rock climbing, wall, trampoline, bungee, jumper, softball, batting cage, golf driving cage, zorb water hamster ball and zipline. There are risks of physical injury or harm from participating in any of the activities listed above.  I voluntarily elect myself or family member listed to participate in the activities and assume the risks of injury or harm that could result from participation.  On my own behalf and that of my personal representatives and heirs, I hereby release Pinecrest, it's officers, employees, and agents and/or Church/group listed from all liability for any injury or harm to me or my family member listed from participating in said activities.  I have read and understood this release.  :
Please list any activities that are underlined and italicized above that you do not want to have camper participate in:
*By checking the 'I AGREE' box and entering my name and today's date, I recognize that this is equivalent to my legal signature and agree to all the terms above.:
* Full Name and Today's Date