Parent Authorization and Medical Consent
My son/daughter, (full name) ______,
has my permission to participate in WINTERCAMP (February 15 – 18, 2013) at Camp St Raphael in Wagoner, OK. I understand that reasonable precautions will be taken to safeguard his/her health and safety, and that I will be notified as soon as possible in any emergency. Also, I will not hold liable any Orthodox Church, its clergy, Council members, staff, volunteers, the Antiochian Orthodox Christian Archdiocese of North American, nor any individual lending or giving his/her private property to be used in connection with this event, for any illness or accident. If I am unable to be reached, and the occasion demands, I further authorize any treatment and hospital care advisable under the supervision of licensed medical physician. Such treatment may include x-ray, examination, anesthetic, medical, dental or surgical diagnosis.
Date: ______Signature: ______
(Parent or Legal Guardian)
(Print name signed above: ______)
HEALTH INSURANCE CARRIER: ______
NAME POLICY IS UNDER: ______
POLICY # / PLAN #: ______
REGISTRATION INFORMATION
NAME: ______
ADDRESS: ______
CITY, STATE, ZIP: ______AGE: ______
CELL PHONE #: ______PARENT CELL PHONE #: ______
EMAIL ADDRESS: ______T-SHIRT SIZE: ______
HOME CHURCH: ______
***Teens should bring with them bedding, toiletries, etc.
WINTER CAMP will begin Friday, Feb 15th at 7 p.m. with dinner
and will conclude Monday, Feb 18th with breakfast.***
Form & $100 registration(Chaperones/Advisors $80.00)
payment due by Tuesday, February 5th, 2013:
St. George Cathedral – Attn: Grace Saad
7515 E. 13th St. N. – Wichita, KS 67206
Contact Erin Ghata (405) 410-9456 or Grace Saad (316) 619-8531 if you have any questions.
*There are no “camp staff members” for Winter Camp. It is organized by our diocese youth directors, who will be traveling with their teens and not arriving in advance. Therefore, we will be unable to provide transportation from the Tulsa airport.