OAK RIDGE UNITARIAN UNIVERSALIST CHURCH

809OAK RIDGE TURNPIKE

OAK RIDGE, TENNESSEE37830

(865) 483-6761

RAINBOW CAMP 2015 June 15-20 REGISTRATION FORM TO BE COMPLETED BY PARENTS

Circle Appropriate Categories: Camper(s) Counselor in Training (CIT) Camp Counselor

List all family participants on this form—campers, CITS, and Counselors.

This form is all that is needed for campers.

CITs/Counselors must also submit a separate job application form.

Participant Full Name______PreferredName ______DOB ______

School (Current) ______Age ____ Grade ____ Gender ____ Ethnicity ______

T-shirt (check 1) Youth Sizes: S __ M __ L __ XL __ Adult Sizes: XS __ S __ M __ L __ XL __ XXL___

Participant Full Name______Preferred Name ______DOB ______

School (Current) ______Age ____ Grade ____ Gender ____ Ethnicity ______

T-shirt (check 1) Youth Sizes: S __ M __ L __ XL __ Adult Sizes: XS __ S __ M __ L __ XL __ XXL___

Participant Full Name______Preferred Name ______DOB ______

School (Current) ______Age ____ Grade ____ Gender ____ Ethnicity ______

T-shirt (check 1) Youth Sizes: S __ M __ L __ XL __ Adult Sizes: XS __ S __ M __ L __ XL __ XXL___

Participant Full Name______Preferred Name ______DOB ______

School (Current) ______Age ____ Grade ____ Gender ____ Ethnicity ______

T-shirt (check 1) Youth Sizes: S __ M __ L __ XL __ Adult Sizes: XS __ S __ M __ L __ XL __ XXL___

Parent(s) Name(s) ______

Home Address______

City, State, Zip Code______

Phone #s Home: (____) ______Cell: (____) ______Work: (____)______

Email: ______

COMPLETE THE OTHER SIDE OF THIS FORM

RAINBOW CAMP 2015

CONSENT, RELEASE AND AUTHORIZATION FOR MEDICAL TREATMENT FORM

I, ______the undersigned, confirm that I am the

parent/guardian of ______

my son(s)/daughter(s). I grant permission for my child to participate in all activities of the Rainbow Camp 2015.

I agree and hereby do release and hold harmless the Oak Ridge Unitarian Universalist Church of Oak Ridge and/or any and all adult supervisors for the activity, from and for any and all liability which may arise for damages, loss or injuries, either to person or property, which my son/daughter may sustain while engaged in the activity conducted, including, but not limited to, any damages, loss or injuries that may be sustained through transportation.

Should injury occur, I grant permission for my son/daughter to receive any first aide and/or emergency treatment from an appropriate health care provider to be selected by the adult chaperone of the activity, when, in such chaperone’s opinion, the need for such treatment is immediate, and when efforts to contact me are unsuccessful. I also agree to pay and be responsible for all medical, hospital, or other expenses which the Oak RidgeUnitarianUniversalistChurch and/or any adult chaperone may incur as a result of securing such treatment.

I further agree to assume responsibility for any liability which may arise for damages, loss or injuries, as described herein which may be caused by my son/daughter to the person or property of others.

  • I give permission for my child to travel by bus to the following city parks for litter pick-up, lunch and play: Mon. Cedar Hill; Tues. Melton Lake; Wed. Milt Dickens; Fri. Bissell (circle one) Yes No
  • I give permission for my child to travel by bus to Chestnut Ridge Landfill in Heiskell, TN and to picnic at Jaycee Park in Clinton, TN. (circle one) Yes No
  • Photos of my child(ren) may be used in Rainbow Camp publicity, including websites and newspapers. (circle one) Yes No

Parent Signature ______Date: ______

Emergency Contact (other than parents) Name ______

Emergency Contact Phone ______

Family Physician______Dr.’s # ______

Health Insurance Provider______Policy # ______

Child’s allergies, physical limitations and/or other information______

______