Event registration
Event Timing: March 31st-April 2nd
Event Address: Camp Paron, 16330 Baptist Camp Rd
Paron, AR 72122
Contact Mark Liggett at (636) 283-3067 or mark@fbcsearcy.org
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Student's Name *
Camper's Address *
Camper's Birthdate *
MM
/
DD
/
YYYY
Camper's shirt size *
Camper's Gender *
Required
Dietary restrictions *
Payment is $40. Are you able to pay or need a scholarship? *
Who invited you? (must be a student invite) *
Parent's Name *
Parent's Phone Number *
Emergency Contact and Phone # *
Parent's Email *
Medical Info *
Primary Care Physician and Phone # *
Allergies *
Does Camper Carry an Epi-pen? *
Are immunizations up to date? *
Insurance Company? *
Insurance Group Number? *
Prescription Medication and Instructions: *
Prescription Medication and Instructions: *
Other Information: *
Other Information: *

The Fine Print

We know the fine print is never fun, but please read the following sections very carefully. If you have any questions, please contact us prior to submitting your registration.

Media and Information Release

I do hereby consent to the recording, use, copyright, and publications of said camper's picture and/or recording by the Arkansas Baptist State Convention its successors and assigns, its clients and/or their advertising agencies of statements made by me, along with the use of my voice, name, picture, and/or likeness. (If camper is a minor, I certify I am the parent or legal guardian of said camper and provide this release.) I understand that such interviews, recordings, likenesses and/or pictures may be used in connection with the following project: DNOW.

I hereby waive any right to inspect and/or approve the finished product or advertising copy or recording that may be used in connection therewith. I release all claims of my own, and agree to indemnify against all claims of others arising out of the making or use of any film, tapes, photographs, or recordings of me.

The above described may be used by the Arkansas Baptist State Convention with no time limit.

I understand that by submitting this registration I consent to the use of said camper's contact information by the Arkansas Baptist State Convention and its agencies. This information is intended only for contact by the ABSC and its agencies in accordance with their purposes and will not be shared with any other individual or organization.

Guardian Medical Consent

I hereby consent and give my permission to any authorized personnel to administer the necessary medication and/or medical treatment to my child (the above named individual) which may be deemed necessary or advisable in the event of injury, accident, and/or illness during his or her camp attendance. I also hereby consent and give my permission to any authorized personnel to take emergency measures deemed necessary for the care and protection of my child while under their supervision. In case of accident or illness, I understand that my child will be taken to an appropriate medical facility for treatment. It is understood that in severe situations, the adults in charge may contact the local emergency resource before the parent, child’s physician, and other adults acting on the parent’s behalf. I understand that any expenses incurred will be the responsibility of the child’s family.

Medication Administration

Information supplied in this policy includes, but is not limited to, medications that are to be administered by authorized personnel. Please note that each medication must be in the original container with the label still intact. All over-the-counter medications (OTC) such as Tylenol, Benadryl etc. must be in the original packaging with a pre-printed pharmacy label providing instructions on use.


Release of Liability (Minor)

I, the undersigned parent or guardian of the above named individual (or “my child”), acknowledge that attendance and participation in all camp-related activities at DNOW may involve the risk of physical injury. I knowingly and freely assume all such risks on behalf of my child and I willingly agree to comply with terms and conditions for my child’s attendance and participation. I agree that I will not make a claim against, sue, or prosecute FBC, Arkansas Baptist State Convention, the Cooperative Program or Ouachita Baptist University, and/or their officers, directors, agents, sponsors and employees for damages for death, personal injury, which my child may sustain as a result of his/her attendance and participation at Super Summer Arkansas. Knowing that there are inherent risks or dangers, I certify that my child is fully capable of attending and participating in the activities Super Summer Arkansas has to offer.

I, as a parent/guardian with legal responsibility for my child, do consent and agree to his/her release as provided above and for myself, my heirs, assigns, and next of kin. I release and agree to indemnify and hold harmless Super Summer Arkansas, Arkansas Baptist State Convention, the Cooperative Program or Ouachita Baptist University from any and all liability incidents to my child’s involvement or participation at DNOW as provided above, to the fullest extent permitted by law. I have carefully read this consent and release of liability and fully understand and agreed to its contents.

Release of Liability (Adult) 

I acknowledge that attendance and participation in all camp-related activities at DNOW may involve the risk of physical injury. I knowingly and freely assume all such risks and I willingly agree to comply with terms and conditions for my attendance and participation. I agree that I will not make a claim against, sue, or prosecute, Arkansas Baptist State Convention, the Cooperative Program or Ouachita Baptist University, and/or their officers, directors, agents, sponsors and employees for damages for death, personal injury, which I may sustain as a result of my attendance and participation at Super Summer Arkansas. Knowing that there are inherent risks or dangers, I certify that I am fully capable of attending and participating in the activities Super Summer Arkansas has to offer.

I release and agree to indemnify and hold harmless Super Summer Arkansas, Arkansas Baptist State Convention, the Cooperative Program or Ouachita Baptist University from any and all liability incidents to my participation at DNOW as provided above, to the fullest extent permitted by law. I have carefully read this consent and release of liability and fully understand and agreed to its contents.

Signature

(If you are a camper under 18, your parent or legal guardian must complete this section)

*
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