*Which Network Church does the student normally attend?:
*Special Needs or Medication:
*T-Shirt Size (Adult Sizes):
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.:
*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
Date attending camp will be June 13 - 17, 2019
The church name is EastLake Church Network.
The Church phone number is 619-421-4100.
*Grade as of June 13th:
CAMPER'S HEALTH INFORMATION
*Does camper have up to date immunizations?:
Check ALL applicable conditions
*Recent broken bones or other injuries:
*History of Sleep walking:
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)
*Pepto Bismol (diarrhea)
*Hydrocortisone Cream (itch/rash)
*Polysporin Topical (minor cuts/burn)
*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?
*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. :