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TeenQuest Camp

Join us for a week of summer fun!  All 7th-12th grade students (as of 2017-2018 year) are invited to spend a week together having fun and deepening their relationship with God.  It will be hosted at Mt. Lebanon and lasts from July 1st-6th (leaving on the 1st at 1:30pm and returning on the 6th at 11:00am).  The cost is $250 per camper and includes transportation, accommodations, meals, and all activities.  In order to secure a spot, you must register below.  Contact Aaron Laramore for more information at aaron@thequestrc.com (972-635-7222). Don't miss an amazing week together, and register today! 

Name *
Name
Birth Date *
Birth Date
Address *
Address
Parent/Legal Guardian Name *
Parent/Legal Guardian Name
Phone *
Phone
Emergency Contact other than Parent/Legal Guardian *
Emergency Contact other than Parent/Legal Guardian
Emergency Contact Phone *
Emergency Contact Phone
Health Insurance Provider Phone *
Health Insurance Provider Phone
Primary Care Physician Phone *
Primary Care Physician Phone
CAMPER MEDICAL POLICY AND INSTRUCTIONS 1. All medications must be properly labeled and kept in original containers. Check expiration dates. No expired medications will be given. 2. All prescription and non-prescription medications must be presented to camp health center personnel upon arrival at Mt. Lebanon.3. All medications must be stored and dispensed from the camp health center (except EpiPens or emergency inhalers). Campers are not allowed to keep or self-administer any medication in accordance with Texas Department of State Health Services regulations. 4. Diabetics must bring a copy of their Diabetes Management Plan. 5. Non- prescription medications such as vitamin supplements or pain relievers will be given only according to the age and dosage restrictions and instructions listed on the package unless a doctor’s order is provided. 6. EpiPens or emergency inhalers may be kept with the camper. (Please send an extra one to be kept in the health center) Health center personnel must be notified immediately when a camper uses an EpiPen. If asthma symptoms are not completely relieved the camper must be brought to the health center for evaluation. 7. List any medical problem, medical alert, allergy, or other relevant health concern/issue under General Health Information. 8. List all medications, dosage and indicate after breakfast, lunch, dinner or bedtime on the Medication Dosage and Frequency Chart. 9. Place all medications and a copy of Page 2 of this form in a heavy-duty, quart sized zip-lock bag with the camper’s name and name of church written with a permanent black marker on the outside of the bag. MEDICATION DOSAGE & FREQUENCY CHART Place all medications and a copy of this page in a heavy-duty, quart sized zip-lock bag. Print the camper’s name and name of church on the outside of the zip-lock bag using a permanent black marker.
Parent/Legal Guardian Signature *
Parent/Legal Guardian Signature
PARENT/ LEGAL GUARDIAN’S STATEMENT OF PARTICIPATION, ASSUMPTION OF RISK, AND RELEASE OF LIABILITY 1. ACKNOWLEDGMENT OF INHERENT RISKS I certify that I am aware of the inherent risks associated with outdoor camp activities, as well as the inherent risks of being on camp property. Notwithstanding, I hereby give my child permission to participate in all camp activities. Further, in consideration for Mt. Lebanon agreeing to accept the above named child as a camper, I hereby personally assume all risks in connection with my child’s attendance and participation in the events at Mt. Lebanon. 2. ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY In the event that my child is injured on camp property or during camp activities, I acknowledge that I shall be personally liable for, and agree to pay, all costs and associated expenses incurred in connection with medical and/or dental services rendered to my child in response to said injury. 3. LIMITATIONS ON INSURANCE COVERAGE I understand that my family/personal health and accident insurance will be the primary coverage. 4. RELEASE AND HOLD HARMLESS AGREEMENT I agree to release and hold harmless the Dallas Baptist Association, Mt. Lebanon Encampment, it’s trustees, employees, agents, and representatives for any injury, harm, or other damage by any occurrence in connection with my child’s participation in camp activities in any form or fashion. I further agree to release and hold harmless Dallas Baptist Association, Mt. Lebanon Encampment, it’s trustees, employees, agents, and representatives from any claim by me, or my family, estate, heirs or assigns out of my child’s participation in activities at Mt. Lebanon. 5. PRE- AUTHORIZATION FOR MEDICAL TREATMENT I hereby authorize any medical and/ or surgical treatment, including but not limited to hospital care, to be rendered to my child, as needed in the judgment of the treating physician, who is chosen by the Camp Director or any employee working under him/her, as circumstances require. I further authorize the Mt. Lebanon health staff to render first-aid and to administer medications as prescribed and programmed on the Dosage & Frequency Chart, executed by the parent or guardian. 6. NON PRESCIPTION MEDICATIONS I give my permission to the camp’s health supervisor, or other health center staff, to administer non-prescription, over-the-counter medications to my child based on symptoms (not a diagnosis). For example, but not limited to, Tylenol or ibuprofen, for mild fever or pain; Benadryl or Claritin, of allergy symptoms; Pepto-Bismol, for diarrhea; cortisone cream, for bug bites; calamine, for poison ivy; and so on. 7. ACKNOWLEDGMENT OF RESPONSIBILITY FOR DAMAGES I agree that I am financially responsible for any damage to camp property caused by my child, including any acts of graffiti. 8. CONSENT TO ADDRESS DISCIPLINARY PROBLEMS The above named camper agrees to obey and observe all camp rules, and to fully cooperate with the adult leadership, camp staff, and other campers. I agree that, if in the judgment of the adult leadership and/ or camp staff, my child becomes a discipline problem, my child may be sent home, at my expense, and that I will forfeit all camp fees paid. 9. USE OF CHILD’S PHOTOGRAPH FOR PROMOTIONAL PURPOSES I agree and consent that my child’s photograph may be used for promotional purposes or publicity material by Mt. Lebanon. I acknowledge that I am the parent or authorized guardian of the above named child. By my signature below, I acknowledge that I have read and understand the information set forth above, including the Release and Hold Harmless Agreement.
Parent/Legal Guardian Signature Date *
Parent/Legal Guardian Signature Date