Pt registration pckt 09

HIGHLAND LAKES CAMP & CONFERENCE CENTER 5902 Pace Bend Rd. North • Spicewood, TX 78669 888-222-3482 • 512-264-1777 • 512-264-2794 (Fax) • ADULT REGISTRATION FORM
INSTRUCTIONS: Individuals 19 years of age or older— Complete the Adult Registration form in its entirety. Indicate date your group desires to
Adult signature is required on each of the 3 pages. All requested information is applicable.
‰ SESSION 1: June 29-July 2, 2009 ‰ SESSION 2: August 3-6, 2009 Adult’s Name: __________________________________________________________________________ ‰ SESSION 3: August 9-12, 2009 First Middle Last (indicate name used) Mailing Address: __________________________________________________________________________________________________________ Street Apt. # City State Zip Birth Date: _____/_____/_____ Age Now :_____ Sex: (M/F) _____ T-Shirt (Adult Size):_____ Social Security No.:______________________ Mo. Day Year Phone Number: Daytime: (_______)__________________ Evening: (_______)__________________ Other: (_______)____________________ Email: __________________________________ Occupation: ____________________________ Employer: ____________________________ I have attended HLC Preteen Camp before: ‰ YES ‰ NO Name of Church or Group with whom you are attending: _______________________________ City: _________________________ State: ____ Have you been convicted of a felony: ‰ YES ‰ NO If yes, explain: ______________________________________________________________ AGREEMENT TO ATTEND, PARTICIPATE,
requires a signature for all attendees of the Camp and all participants of any Camp activity including, but not limited to, Challenge/Ropes Course (highs
and lows), Water Crafts, Water Toys, Swimming Pool, Bicycle Course, Backpacking, Camping, Basketball, Football, Baseball, Softball, Volleyball, and
any and all other camp and recreational sports and activities. Furthermore this form releases the Camp to photograph and/or use photographs of
myself or my child for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the
services and activities of Camp. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to
attend Camp and to participate in any Camp activity.
Attendance and Activities at Camp may include warms-ups, games, group initiative problems, high and low challenge course, and/or other rigorous
physical adventure activities as well as exposure to the elements, exposure to animals, snakes and insects. Camp takes all reasonable precautions to
ensure you a safe and enjoyable experience. Parts of the experience, by their nature, can be physically demanding and include varying levels of stress
and anxiety, not all of which can be foreseen. The decision to attend the Camp and the decision to participate in any Camp activity at any level IS AT
and, if there is attendance at the Camp and participation at any level of any Camp
activity, there is a risk, which must be assumed by each attendee and by each participant. Although it is the Camp’s goal to maintain the physical,
emotional and social safety of each attendee and participant of the Camp, the physical, emotional and social risks must be assumed by each attendee
and participant.
“I understand that attendance at the Camp and participation in any Camp activity may be physically and emotionally demanding. I recognize the
inherent risk of physical and/or emotional injury of attending Camp and participating in any and/or all Camp activities. I understand that each
participant must assume the risk of any injury, physical and/or emotional, and any financial responsibility that could result from attending Camp and
participating in any Camp Activity. I agree to assume such risks and such responsibility. I, on my behalf, and on behalf of my heirs and
assigns, hereby release, indemnify and hold harmless Highland Lakes Baptist Encampment d/b/a Highland Lakes Camp and Conference
Center from any and all claims, physical and emotional, including bodily injury, that I may have sustained in connection with my attending
Camp and with my participation in any and/or all Camp activities.”

If you feel that there are any activities in which you or your child should not be involved in, please describe for us on an attached sheet the activities (include name and church/group name on the attached sheet). I understand the directors of Highland Lakes Baptist Encampment reserve the right to dismiss, without refund, any camper whose influence is detrimental to the operation of the camp, as determined by the discretion of the directors. I understand that the use of alcohol, tobacco products, and illegal drugs is strictly prohibited at all Highland Lakes Baptist Encampment programs. I have read (or had read to me) this complete document and I understand the information contained herein. I have freely and voluntarily signed this document. X____________________________________________________ _____________ Required Adult Attendee/Participant Signature IMPORTANT. SEE REVERSE SIDE FOR MANDATORY MEDICAL RELEASE & SIGNATURE(S)
Page 1 of 3 –Adult Medical / Liability Waiver Form Page 2 of 3 –Adult Medical / Liability Waiver Form GENERAL CAMP RULES
All medications are to be listed on the Registration/Medical Release form, registered with the HLC medical staff and taken to the Health Center. All medications must be in original bottle and/or container. Medications will be administered as per RX label instructions and dosage, unless written, signed, and dated parental instructions state otherwise. A completed Medication Administration Form should be provided with the medications. Guests are not to share any medications, including over-the-counter medications. Guests who are ill or injured must be either in the HLC camp office, medical clinic, or hospital. In the event of illness or injury, students will not be permitted to remain in their dorm rooms. Prank supplies are not allowed in the dorms (i.e. shaving cream, body paint, water balloons, water guns/blasters). There are no exceptions. Adult supervision is required at the lake and/or pool. At no time is a student to go to the lake and/or pool without adult supervision. Lifejackets are required for lakefront activities, regardless of a person’s age or water safety ability. Drugs, alcohol, any form of tobacco, firearms, knives, or any kind of weapon, matches or fireworks are NOT allowed. Guest should not bring the following to camp: Cell phones, iPods, mp3 players, video games, CD players, television, laptop computer, play sta-tion or any other type of electronic games or equipment should not be brought to camp. Keepsake or valuable jewelry, collectible or memorabilia sportswear should not be brought to camp. HLC will not be responsible for the misplacement or theft of guest personal property. Skateboards, rollerblades, heely roller shoes are not allowed.
Guests are discouraged from bringing food items. Snacks will attract ants in the dorms. We suggest that if you bring snacks, that the food be stored in tightly sealed containers, such as a plastic storage container or zip-lock plastic bag. No electric appliances to be used for food prepara-tion is allowed. The HLC Concession stand will be open throughout the day and each evening. Guests (students and adults) are expected to reflect a Christian example by their dress. Counselors, parents, and church leaders are
for the clothing and appearance of the youth and adults attending camp. The manner of dress should be set and clearly communi-
cated prior to leaving home. Modest skirts, dresses, shorts, and jeans are acceptable in worship. Immodest short shorts or tops, small tank
tops, tight clothes, spaghetti strap tops, distasteful designs or messages, cheer shorts and other extreme clothes are not acceptable at any time.
Shorts must be longer than the arm and hand when extended down the side of the person. Only one-piece swimsuits or tankinis that cover more
than 80% of the stomach are allowed. Bikinis, French cut or one-piece swimwear that resembles two-piece will require a dark colored t-shirt to be
worn over them. Campers may be asked to change their attire if an adult or HLCCC staff feels their dress is inappropriate.
10. Refrain from Public Display of Affection with others. 11. Under NO circumstances are girls to be in guys rooms or guys in girls rooms. 12. No fighting or inappropriate / profane language is allowed. 13. Students are to respect all adult leaders and follow their instructions. All adults–members of HLC leadership team, church leadership teams, and adult volunteers–are in places of authority over all students. They have been trained in how to guide students for each particular event. 14. Everyone must attend all scheduled events. If your group is in an activity, whether in the classroom or on the athletic field, you must be with them. There are no exceptions to this unless you are injured or sick and are at the HLC Health Center, doctor’s office or hospital. 15. Guest MUST be in the dorm by designated camp curfew. Your curfew is for your security and for your mental and physical well-being. 16. Guest must wear nametags at all times. Each Camp participant will be issued a nametag upon arrival, which is to be worn during all meals, and 17. Guests are not allowed to leave Highland Lakes Camp without proper parental written authorization and approval of HLC administrative staff. 18. Guests are not allowed to bring pets on campus. No pets in the dorms, motels, or meeting rooms. 19. Guest and/or church group leadership will be held financially responsible for any property damages that occur during their stay at HLC. Campers should refrain from writing on furniture or walls. Do not use duct tape to affix signs to doors or walls. 20. For your safety, guests are not allowed on any HLC “RESTRICTED” property areas. ADULT CONTRACT
I have read the General Rules listed above and promise to abide by The person above is known by me. To my knowledge, this person has all established regulations for my enjoyment and for the safety of all not been convicted of any crimes committed against minors in his/her participating in Camp. I understand that I may be dismissed from back-ground. I assume full responsibility for this person serving as a Camp and sent home at my own expense if I do not adhere to the camp sponsor/counselor working with minors. X _____________________________________ __________
X _____________________________________ __________
Signature of Pastor, Staff Member, or Group Director Date Page 2 of 3 –Adult Medical / Liability Waiver Form Page 3 of 3 –Adult Medical / Liability Waiver Form ADULT MEDICAL RELEASE FORM
In the event of an accident or special health needs, it will be necessary for us to have the requested information. Please make certain that you have provided thorough and accurate medical information. It is recommended that you attach a photocopy of your family medical insurance card. Name of Adult Sponsor: _________________________________________________ Birth Date: _____/_____/_____ Age: ___Sex: (M/F) _____ First Middle Last Mo. Day Year Church: ________________________________________________ City: _____________ Dates at HLC: _____/____/____ to _____/____/____ Person to Notify in Event of Emergency: ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________ If unable to reach above person: Notify ______________________________________________ Relationship to You: __________________ Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________ Family Physician: _________________________________________________ Phone: (_______) ______________________________ Medical Insurance Co.: ____________________________________________ Plan or Group #: ________________________________ Insured ID or Member #: ___________________________________________ Ins. Co. Phone #: (_______)_______________________ MEDICAL INFORMATION
Diseases, Chronic or Recurring Illness: (Check all that apply, explain) ‰ Asthma: _____________________________________________ ‰ Food: ________________________________________________ ‰ Bleeding Disorder: ____________________________________ ‰ Insect Sting: __________________________________________ ‰ Dermatological Condition: ______________________________ ‰ Medicine/Drug: ________________________________________ ‰ Diabetes: ____________________________________________ ‰ Plant/Pollen: __________________________________________ ‰ Ear Infections: _________________________________________ ‰ Other: _______________________________________________ ‰ Heart Defect: __________________________________________ ‰ Seizures: _____________________________________________ Special Diet: ____________________________________________ ‰ Stomach Condition: _____________________________________ Recent Surgery? _________________________________________ ‰ Emotional: ____________________________________________ Date of last Tetanus Shot? ______ Immunizations Current? ______ State law requires all medications to be placed in the campus Health Center. All medications must be brought in the original container (prescription or over-the counter) properly labeled as prescribed by law. Prescription labels must have the camper’s name and current dosage. A current Medication Administration Authorization Form MUST accompany all medication. Medications and Administration instructions will be collected and reviewed by HLC Medical staff upon camper arrival. HLC Medical staff requests that you NOT send over the counter medications such as Tylenol, Ibuprofen, Be-nadryl or antihistamines. HLC Medical Staff stock an assortment of over the counter medications for the occasional need. HEALTH CARE AND CAMP PERMISSION— INITIAL & SIGN THE STATEMENTS BELOW.
___ I give my permission for first aid techniques and simple health care to be administered as the need arises. I understand in the event of any seri-ous injury or illness on my part the camp officials reserve the right to seek professional medical attention including but not limited to consultation with medical director, EMS transportation, and hospitalization. ___ I give permission for myself in consultation with the Camp Health Supervisor and/or the medical director’s standing orders to take the following medications as indicated by checking below: ___antihistamine (i.e. Benadryl, Claritin) ___additional medications as indicated/prescribed by the HLC Medical Director I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that I am in acceptable heath, physical ability, and emotionally ready to fully participate in camp. I grant my permission to participate in all activities associated with the enrolled event with the exceptions of those that are noted. I, _______________________________ give my permission to Highland Lakes Camp and Conference Center’s management, medical staff, and/or the group director to provide medical treatment that may be deemed necessary to insure my well-being. I, the undersigned, do hereby release and forever discharge all from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in Highland Lakes Camp sponsored activities. X ___________________________________________________ ____/____/____ (_______) ____________________________
Name: ______________________________________________________ Birthdate: _____/_____/_____ Age: ___ Sex: ___ Male ___ Female Church group student came with: ___________________________________ Church City & State: ______________________________________ As the parent or legal guardian of the above-named child, I give my permission to the enlisted Highland Lakes Medical Staff to administer as prescribed by law the listed below medication to my child. ___________________________________________________ _________ (______) ____________________ (______) ___________________ Parents/Guardian Signature Date Daytime Phone # Evening Phone # For Prescription Medications only.PLEASE follow these guidelines:
In accordance with Texas Department of Health regulations: ALL Medication that is brought to camp must be: (1) Placed in the Health Center, Prescribed for the camper (not a sibling or parent), (3) In the original container with all labels intact, and (4) Correct current dosage. Dosage of non-prescription medication may not exceed product recommendation without doctor’s written orders. HLC Medical Camp staff request that you do not send over-the-counter medications (i.e. Tylenol, Ibuprofen, Benadryl, etc). These types of medication, as are others, is provided by the camp. Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ If necessary, make additional copies of this blank Medication Form in order to provide requested information for each medication. All Medication
Release/Administration Forms and medication(s) to be administered should be given to the church Contact Person prior to arriving at camp. When
the church group arrives at camp, the Contact Person will be responsible for bringing all medications and forms to the camp registration area. The
Forms will be reviewed by our Medical Staff to clear up any possible questions about medications or their administration. To make it easier for the
church Contact Person, the parent/or student should put their medications and forms in a zip-lock type plastic bag with the student’s name and church
written with a marker on the outside of the bag. Parents should emphasis to their child(ren) the responsibility of reporting to the camp Health Center
for their medications while at camp.



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CURRICULUM VITAE Peter G. Gulick, DO, FACOI, FACP, FIDSA (Office) Michigan State University, B318 West Fee Hall, East Lansing, MI 48824 (517) 353-3211 (Clinic) Ingham County Health Department, 5303 S. Cedar Street, Lansing, MI 48909 (517) 887-4302 (Clinic) Breslin Cancer Center, Ingham Regional Medical Center, 401 W. Greenlawn, (Home) 1839 Pine Knoll Road, Okemos, MI 48864, (517) 349-4

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