Xapa Teen Camp 2024

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Xapa Teen Camp 2024

First Name *

Last Name *

Gender *

Female

Male

Church

Church on the Rock

First Baptist Church of St. Bernice

Harmony

The Refuge

The Well

Other

I did not come with a church

Clear selection

Age *

T-Shirt Size *

Adult S

Adult M

Adult L

Adult XXL

Adult XXXL

Youth S

Youth M

Youth L

Youth XL

If applicable, list one or two campers your child would like to share a cabin with.

Is this your first year with Xapá?

Yes

Clear selection

Did a fellow camper invite your child, if so, who?

Parent/Guardian Name *

Parent/Guardian Address (Street, City, Zip Code) *

Phone Number *

Email *

Health Insurance Carrier & Policy Number

Policy Holder's Name & Relationship to Holder

Allergies *

Medications Taken *

Any physical, medical, or dietary conditions we should know about?

In the event that my child is to suffer form any common ailments I grant permission to treat my child’s condition with over the counter medications. *

Yes

Required

Emergency Contact Name & Phone Number *

I give my give permission to Xapa` Ministries to take and post photos of your child on the internet using Facebook, camp website and/or promotional materials. *

Yes

Required

I/We give my/our permission for my/our child to participate at Xapa' Ministries Teen Camp July 7-11, 2024 and travel by all means necessary by the Camp’s schedule. *

Yes

Required

I/We authorize the participation of my/our child in this event, including all activities and travel involved. I/We represent and warrant to Xapa' Ministries my/our child is physically able to participate in the event and has no physical limitations or conditions that would affect his/her well being that we have not disclosed. Although Xapa' Ministries desires to provide a safe and enjoyable time for all campers, I/we understand that accidents can still happen. I/We understand that there are risks and dangers involved with participation in a camping environment and its associated activities. In consideration of my/our child being allowed to participate in the event, I/we hereby assume responsibility for those ordinary and reasonable risks associated with the event, its activities and associated travel. I/We, on behalf of my/our self and my/our child, hereby waive, release and fully discharge and agree to indemnify and hold harmless the Xapa' Ministries, it's officers, volunteers and those participating in the leadership of this event in any capacity, including volunteers and other drivers and medical personnel, from any and all claims. liability, damages, actions, causes of actions, or suits of law or in equity, of any kind or nature whatsoever which may occur at any time, and any way arising from my/ our child’s participation. This release does not apply to claims of intentional misconduct or gross negligence by Xapa' Ministries, its's officers or volunteers. In case of accident, illness or other medical emergency, I/we request that Xapa' Ministries contact me/us at the phone numbers listed above. If they cannot reach me/us, or if the medical emergency requires immediate treatment, I/we give permission for Xapa' Ministries staff, officers and/or volunteers to obtain treatment on behalf of my/our child, which, in their best judgment is deemed advisable. I/We agree to assume full financial responsibility for all expenses incurred. I/We agree and have so instructed my/our child that he/she will obey the instructions of the camp leaders and supervisors and will comply with all standards of behavior of the camp. I/We assume full legal and financial responsibility and liability for the actions of my/our child, and agree to indemnify and hold harmless Xapa' Ministries, it's officers, volunteers and those participating in the camp, for the actions of my/our child. I/We understand and agree that is my/our child fails to obey the rules or instructions, he/she may be sent home early at my/our sole cost and expense. *

Yes

Required

Parent Signature By selecting the "I Accept" button, you are signing this Permission, Waiver, Release and Authorization for Emergency Medical Treatment electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Permission, Waiver, Release and Authorization for Emergency Medical Treatment. By selecting "I Accept" you consent to be legally bound by this Permission, Waiver, Release and Authorization for Emergency Medical Treatment's terms and conditions. *

I Accept

Parents Printed Name *

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