Download - Registration Form Brochure 2010
-
8/14/2019 Registration Form Brochure 2010
1/12
-
8/14/2019 Registration Form Brochure 2010
2/12
-
8/14/2019 Registration Form Brochure 2010
3/12
-
8/14/2019 Registration Form Brochure 2010
4/12
SPIRITUAL FORMATION
Camps Kateri Tekakwitha combine demanding outdoor activities
with powerful spiritual instruction bringing about a unique
encounter with God. Although our adventure activities arememorable, often the love that campers experience throughprayer is what kids remember most. Your child will have the
opportunity to experience different forms of prayer during camp.
Adoration, Reconciliation, veneration of the cross, rosaries,litanies, Mass, informal group prayer and individual
reflection are among the many styles of prayer we
practice here. These prayer experiences will have alasting impact on campers ONLY IF they are livedout and continued. We encourage you to pray for
your children during camp and with them aftercamp.
FromI-35,taketheW
illiamsburgexit(#170
)and
drivesouth,awayfro
mgasstation,8/10ofa
mileto
WilliamStreet.(Williamsburgsmainstreet)
.Turn
right(west)onWillia
mStreetanddrive1/10ofa
mile.Turnleft(South)onCaliforniaRoad(g
ravel
road).Proceedapproximatelymile.PrairieStar
Ranchisontheright
(largestonesmarkentrance).
DIR
ECTIONS
VISITORS/USE OF PHONE
Campers do not have access to phones. Camp directors will
monitor any need for campers to use the phone. Parents may calloffice personnel to check on their childs well being.
We strongly encourage parents to write yourchild and place letters in inner-camp mail onopening day of camp; they really do enjoy getting
your letters. Letters that are received, via the mail,
after a camper has left, will be shredded. Onlyauthorized guests are allowed on the premises
during camp sessions. No pets allowed.
CHARGES/REFUNDS
A $100 non-refundable deposit is due with each registration.
The balance is due May 15. Registrations submitted after May 15need to include full payment. If cancellation becomes necessary,
and if your campers spot can be filled, you will receive a refundminus your deposit. Refund claims must occur within one monthof the camp session closing. If a camper is wait listed and does
not get into a camp, the deposit check is voided and destroyed.
Please use the following numbers to answer your questions:
Registration Questions (Calls returned in 24-48 hours)
Camp Info Line 913-647-3054 or [email protected]
Camp Policies/Camp Activities
Shawn Madden 785-746-5693 or [email protected]
Donations/Camp Safety
Dana Nearmyer 913-647-0331 or [email protected], (June 1-Aug 8) 785-746-5693
To Download Forms and Brochures: go to www.archkck.org,Mary Rukavina 913 647-0373 or [email protected]
-
8/14/2019 Registration Form Brochure 2010
5/12
ww
w.archkck.o
rgregistero
n-line!
RegistrationInstructionO
verview
INTERNETAND
MAILAPPLICANTSMUSTALLTURN
IN
THE
ENCLOS
ED
REGISTRAT
ION
FORMSA.S.A.
P.AFTER
FEB
1,2010orFEB.8,2010
Tim
elineandMethodsofRegistration:
Registrationbeginsfor
7ththru12thgradecampersonFebruary1,2
010(Online9:00a.m.).
Registrationbeginsfor
5th&6thgradecampersonFebruary8,2010
(Online9:00a.m.).
Registrationspostmarked
and/orreceivedpriortoF
ebruary1stfor7ththru12thgradecamperswillbe
returned.Registrationpostmarkedand/orreceived
priortoFebruary8thfor5th&6thgradecampersw
illbe
returned.PleaserespecttheFebruary1standFebruary8thregistrationdates
orthiscouldcauseyourchildto
losehisorherplace!NO
HAND-DELIVEREDR
EGISTRATIONSWILLBEACCEPTED.
Campsessionsfillveryquickly!Spotsarereserved
onafirst-come,first-servebasis.Manycampspots
are
availableforregistrationsreceivedthroughthemail.H
owever,weencouragethe
useofouronlineregistration
system.Usingonlineregistrationwillgiveyouinstantconfirmation.Mailapplicantswillreceivea
confirmationorwaitlistletterthreeweeksafterreg
istration.Finalbalances
aredueMay15,thruonlineor
checkpaymentoptions.
Toregistergotowww.ar
chkck.organdfollowregistrationinstructions.Ifyo
uwishtobecomeamemberof
ouron-linecommunity,gotoLoginandCreateaNewAccount.Membershipwillinsureyourreceiptof
campupdatesviae-mail.
Registrationsarenotacceptedwithoutcompletedhealthforms,aphotocopyofhealthinsurancecard,
walletsizephotoofcamper(willnotbereturned)andanon-refundableandn
on-transferabledepositamount
of$100.Eachcamperwillneedtobringtocamponopeningday,theHealthEx
amWaiver(onepageArchkck
form)orasportsphysical,
notmorethan24monthso
ld,signedbyalicensedmedicalprofessional.
Plea
seusethefollowingnumberstoansweryo
urquestions:
RegistrationQuestionsCampInfoLine913-647-3054orjenniferarchkck@sun
flower.com
Cam
pPolicies/CampActivitie
sShawnMadden785-7
Donations/CampSafetyDan
aNearmyer913-647-033
(June1-Aug3)785-746
-5693
Pleasegiveus24-48hourstoreturnyourcallsbeforecallingagain.
ToD
ownloadFormsandBrochuresgotowww.archkck
.org.Campbrochureincludespoliciesandprocedu
res,
arriv
alanddeparturetimes,directions,packinglist,etc.
Beforeyoucall,please
checkthewebsiteforthe
answ
erstoyourquestions.
Fam
ilyCamp:
The
informationinthispack
etdoesnotcompletelye
xplainfamilycamp.Fam
ilycampisanextraordinary
expe
rienceaboutwhichwelo
vetospreadtheword.Allfamilieshavetheirow
ncabin.Allcabinsa
re
air-c
onditioned.Eachfamily
hasitsownwaitstaff.M
ealsarereallyfun.Tablesareclearedbyyour
personalwaitstaff.Thepriceisall-inclusive,(notippingplease).Familycam
pbringsfamiliescloser
together.Teens,toddlers,pa
rentsandgrandparentslovefamilycamp.CallDanaNearmyerat913-647-0331
[email protected](June
1-Aug8)785-746-5693
ifyouhaveanyquestionsaboutfamilycamp.
YouthResidentialCampScholarshipsareavailable.Applications
aredueJanuary20,
2010.
Ifyo
umissthescholarshipde
adline,youmaymailyourapplicationlate.Inthe
eventadditionalfundsare
donated,additionalapplicatio
nswillbeconsidereddur
ingtheregistrationproce
ss.Forspecificquestions
rega
rdingyourapplicationsu
bmission,[email protected].
-
8/14/2019 Registration Form Brochure 2010
6/12
CAMPSKATERI
TEKAKWITHA2010
AllCam
psareHeldat:
PRAIRIE
STARRANCH
1124C
aliforniaRoad
Williamsburg,Kansas66095
HEALTHE
XAMWAIVER
CAMPERSNAME:________________________
_________________________
CAMPERSADDRESS:_____________________
_________________________
CAMPSESSION/DATE
:__________________________________________
___
CAMPERSGRADEFALL2010:_____________
_________________________
____________________
_____________
(camper)isphysicallyfittoattendca
mpatCampsKateri
Tekakwitha.Thedateof
lastexamwas__________
_______________
(within
thepast24months).Pleaselist
currentongoingtreatmentsormedications,if
any.____________________________________________________________________.
Date_________________.
___________________________________
LicensedMedicalProfessional
Date_________________.
___________________________________
ParentorGuardian
Thecampsofferhorsebackriding,highropeschalle
nge,canoeing,hiking,orie
nteering,rockclimbing,
rappelling,basketball,soccer,swimming,grouppartygames,archery,volleyba
ll,mountainbiking,mountain
boarding,outdoorcampin
g,softball,numerousCatholicprayerandsacramentalexperiences,andother
outdoorcampactivities.Notallactiviteswillbeava
ilablefor5th &6th gradecampers.Nocamperwillbe
forcedtoparticipateinan
yactivityatwhichtheyare
uncomfortable.
THISFORM
SHOULDBEBROUGHTTOCAMPON
OPENINGDAY.
DON
OTMAIL.
-
8/14/2019 Registration Form Brochure 2010
7/12
CAMPS
KATERIT
EKAKWIT
HA2004
RegistrationAddress:Cam
pTekakwitha A
rchdioceseo
fKCinKS 1
2615ParallelParkway K
ansasCity,KS66109
CampAddress:PrairieStarRanch 1124California
Road,Williamsburg,Kansas66095 Tel785/746-569
3
CAMPS
KATERIT
EKAKWITHA2010
@PrairieStarRanch
P
leasemailto:CampTekakwithaArchdioceseofKCinKS1
2615ParallelP
arkwayKansasCity,KS
66109
REG
ISTRATION&HEALTHFORM
-FORALLYOUT
HCAMPS
ListChoicesinOrderFromF
irstToLast(1,2,3,4,).
ListChoicesinOrderFromF
irstToLast(1,2,3,4,).
ListChoicesinOrderFromF
irstToLast(1,2,3,4,).
ListChoicesinOrderFromF
irstToLast(1,2,3,4,).
PleasenoteN
/AforsessionsthatyourcamperisNotAvailabletoattend
.
PleasenoteN
/AforsessionsthatyourcamperisNotAvailabletoattend
.
PleasenoteN
/AforsessionsthatyourcamperisNotAvailabletoattend
.
PleasenoteN
/AforsessionsthatyourcamperisNotAvailabletoattend
.
Tekakwitha
&X-Treme
Entering9th12th
gradesinFall2010
(includinggrad
uatingseniors)
CampTe
kakwitha
June21-26$
380__________
Tekakwith
a-X-Treme
July26-Aug3
$430________
Pleaseseebrochurefor
arrival/departuretimes
PRIORTOregisteringyourchild.
Camps
Kateri
Entering5th&6th
gradesFall2010
Term1
June1-3
$230______
Term2
June4-6
$230_______
Term3
June28-30
$230_______
Term4
July6-8
$230______
Pleaseseebrochurefor
arrival/departure
timesPRIORTOregisteringyourchild
FamilyCamp
July16-18
Agesnewborn2
Free
(nobab
ysittingprovided)
Ages2yearsandUp$125
SEEFAMILYC
AMPFORMTOSIGN
UP
Camp
sTekakwitha
Entering7th
&8thgradesFall2010
Term1
June
7-12
$370_______
Term2
June
14-19
$370_______
Term3
July10-15
$370_______
Term4
July19-24
$370_______
Pleaseseebroch
ureforarrival/departuretimes
PRIORTO
registeringyourchild.
VeryImporta
nt!Haveyoualread
yreservedaspotonline?YES/NO.
C
ampersName___________________________
_________
Age(atcampt
ime)_____
DOB:__
/___/___
G
radeinupcomingyear_
__________
MALE
FEMALE
Phone#
(_____
)________________
StreetAddress_________
______________________________ParentEmail__________________
___
C
ity_________________
__________________________
State________
____
Zip______________
Parish___________________________________
_______
ParishCity___
_______________________
M
othersName________
_________________Ph
one(Day)(____)________
(Evening)(____)______
___
M
othersCompleteAddre
ss(ifdifferentthancamper)__
_______________________________________
___
FathersName__________________________
Phone(Day)(____)________
(Evening)(____)______
___
FathersCompleteAddress(ifdifferentthancamper)___
_______________________________________
___
Emergencycontact(incase
youcantbereached)_______
_______________________________________
___
Phone#(____)_____________________
Relation
tocamper______________________________
___
O
necabinmate,ofsamegenderandgrade,requestispermitted____________________________
___
(Seecamppacketfo
rcabinmaterequestdeta
ils)
Emergencynumbers(cell
phonenumbers)forparentsduringcampweek________________________
_____________________
_______________________________________
_______________________
Page 1 of 3 Youth Residential Camp
-
8/14/2019 Registration Form Brochure 2010
8/12
Page 2 of 3 Youth Residential Camp
Pleasenotethereare4requiredsignatures!!!
Isthisparticipantingeneralgoodhealthandabletoparticipateinnormalcampactivities?
Yes_____
No
_____
Dateofmostrecentphysica
lexaminationbyalicensedmedicaldoctor.Date:__
__/____/____
(Ifupcomingappointmentset,pleasenote:_______________________________
__________________________.
)
!!!!VERYIMPORTANT!!!!
YouMUSThavewrittenverificationFROMLICENSEDMEDICALPERSONNELthatthecamperha
shada
healthexaminationdur
ingthepast24monthsand
therecordSHOULDINC
LUDE:anyphysicalcondition
requiringrestrictionsonparticipationincampand
descriptionsthereof,dateofexam,andcurrenton-go
ing
treatmentsormedications,andtherecordshouldbesignedanddated.PleasefilloutourHealthExamWaiver
(onepageArchkckform)orasportsphysical,not
morethan24monthsold,signedbyalicensedmedical
professional.THISINFORMATIONMUSTBEBROUGHTWITHYOUT
HEFIRSTDAYOFCAM
P.
PLEASEDONOTMAIL.(ThisInformationRe
quiredbyAmericanCampingAssociation).(HealthE
xam
Waiverformattachedtocamppacket.)
DoctorsNameandClinic:______________________
___________________________________________
_____
DoctorsFullAddress:_________________________
___________________________________________
_____
DoctorsPhone#:(_____)_
___________________
Areallimmunizationsupto
date?Yes_____
No___
__
(Ifupcomingappointmentset,please
note:__________________
.)
Dateoflasttetanusbooster:____/____
/____
(Tetan
usBoostersareRequiredE
very10years.)
Ifanyarenotuptodateple
aselistthem.
______________________
___________________________________________
____
MEDICATION
Allergies/Conditions:(Checkifparticipantisallergictoanylistedorhasanyofthefollowingconditions)
BeeStings______
PoisonIvy______
Asthma______
Fainting______
Penicillin______
Sulfa______
Seizures______
HayFever______
Latex________
FirstAidAntiseptics____
Antibiotics_____
Other________
Ifanyoftheabovewerecheckedyes,pleasesubmita
statementinspaceprovidedbelowofhowthechildhasbeen
treatedandwithwhatmedications.Pleasealsolist(us
ebackofpage3ifnecessa
ry):
1.Anyoperationsorseriousinjuryinthepasttwoyears.
2.Medicallimitations
orneedsthatweneedtobeawareof.
3.Anylimitationsorn
eeds(learningstyles,familysituations,custodyarrangements,etc.)
Ifyourson/daughterwillbe
takingover-the-counterorprescriptionmedicationswhileatcamppleaselistALL
medications(over-the-coun
terANDprescriptions)nam
e,dosageandfrequencyo
na3x5cardandplaceina
ziploc
bagwithyourchildsname
onitalongwiththemedications.Prescriptionmedicationsmustbeinoriginalcontainer.
Anychangesinmedication
mustbereportedwhenreg
isteringatcamp.Nomedication,evenTylenol,willb
e
dispensedtoyourchildotherthanwhatyouprovide,u
nlessanemergencysituationdictates.PleasesendTy
lenolif
youchildissusceptibletoh
eadaches.
Theziplocbag,andallothermedication,prescriptionandnon-prescriptionmedicationwillbecollectedat
registrationanddispensedbytheassignedteamperson.YouthmaynotkeepANYmedication.
#1Signature________________________________
_________________________
Date_____________
___
(Parentor
Guardianpleasesignevenifchildnotonmedication)
-
8/14/2019 Registration Form Brochure 2010
9/12
Page 3 of 3 Youth Residential Camp
Pleaselistanyspecialdietaryneedsforyourchild.___________________________________________________
______
___________________________________________
___________________________________________
Notify
thedirectorifthischildisexposedtoanycommunica
blediseaseduringthethreeweekspriortocamp
Parentswillbenotifiedoffever,v
omiting,intensehomesicknessoranxiety,areasthatrequiregauzebandaging,x
-raysor
stitchin
g,andofothersituationso
fconcerntodeterminethe
courseofactiontobetaken.
Incase
ofmedicalemergency,Iunderstandthateveryeffort
willbemadetocontactparentsorguardiansofcamper.Inthe
eventthatIcannotbereached,IherebyrequestandgivepermissiontothephysicianselectedbytheCamptohospitalize,
securepropertreatmentfor,andtoorderanesthesiaorsurgeryformychild,asnamedh
erein.Insigningthishealthform,I
hereby
certifythattheinformation
iscorrectandgivepermis
sionforthereleaseofmedicalrecordstoanattending
physician
incase
ofillnessoremergency.I
requestthatmychildbetransportedtoseekneededm
edicalattention.
#2ParentorGuardianSignature________________
______________________________
Date________
_______
Health
InsuranceCompany_____
___________________________________________
______________________
Health
InsurancePolicy#______
___________________________________________
______________________
PrimaryHealthInsuranceholder,
nameandSocialSecurity#________________________________________
APhotocopyofthePrimaryHealthInsur
ancecardMUSTbesubm
ittedwiththisform.
Irequestthatmychild_________
___________
beallowedtoparticipateinthecampactivitiesatCampKaterior
Camp
Tekakw
ithaattheArchdiocesanC
ampinWilliamsburg,KS.IherebyreleaseandindemnifytheArchdioceseofK
ansasCity
inKansas,itsstaff,andvolunteersfromanyliabilityarisingfromclaimsofanykindor
naturewhatsoeverfrommychilds
participationinthisprogram.The
activitiesmayincludehor
sebackriding,highropesc
hallenge,powerkiting,stuntkiting,
canoeing,hiking,orienteering,rockclimbing,rappelling,basketball,soccer,swimming,technicaltreeclimbing,groupparty
games,
archery,volleyball,mountainbiking,mountainboarding,outdoorcamping,softball,numerousCatholicprayer
experie
nces,andotheroutdoorcampactivities.
#3Pa
rentorGuardianSignatu
re_________________________________________
_Date________________
FullAddress______________________________________
___________________________________________
SignatureofCustodialParent(ifa
pplicable)_____________
___________________________________________
PHOT
ORELEASE
IherebyauthorizetheArchdioceseOfKansasCityinKansas,anditsagentstoutilizem
ychildsphotographicimageforthe
specificpurposeofpublicationof
theArchdioceseOfKansasCityinKansasevents(includingpromotionalmaterials).In
givingmyconsent,IherebyreleaseandholdharmlesstheArchdioceseOfKansasCity
inKansasanditsagentsfromanyand
allresp
onsibilityorliability.Iund
erstandthatIwillreceivenocompensation,shouldanyphotographofmeormy
childbe
used.
#4ParentorGuardianSignature________________
__________________________________
Date____
_________
TRAN
SPORTATIONHOME
Attheconclusionofcamp,yourc
hildwillbeleavingwithhis/herparents.Yes_____N
o_____
Iamno
tabletopickupmychildfromcamp;he/shehasmy
permissiontoridehomewith___________________________
Campe
rwillnotbeallowedtolea
vewithanyonewhoisnot
namedonthisform.
COMP
LETINGREGISTRATIONRegistrationisNOT
completewithoutthefollowingitems:
1.
Makesureallblanksontheformarecompleteandallfoursignatureblanksaresigned.
2.
Encloseaphotocopyofhealthinsurancecard.
3.
Sendawallet-sizephoto
ofcamper(willnotberetu
rned).
4.
En
5.
6.
Enclosea$100non-refundabledepositcheckmadepayabletoCampTekakwitha.
5.
EarliestACCEPTEDpostmarkdate:February1,2010,for7ththru12gradec
ampers
andFebruary8,2010,fo
r5th&6thgradecampers.
Earlierpostmarkswillbe
returned!
-
8/14/2019 Registration Form Brochure 2010
10/12
FAMILY
CAMPTEKAKWITH
A2010
PrairieStarRanch
Pleas
emailto:CampTekakwithaArchdioceseofKCinKS12615ParallelParkway
KansasCity,KS66109
REGIST
RATION&
HEALTH
FORM
FORJu
ly16-18FAM
ILYCAMPO
NLY
Pleaseprintanduseblueorbla
ckinkonly.
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
Camper
sName________________________________
____Age(atcamptime)_____DOB:__/___/___
HomeP
hone#(_____)________________
A
dditionalPhone#(____
_)________________
StreetA
ddress______________
__________________E
-mailAddress________
_________________
City______________________
_____________________State____________
Zip______________
Parish_
_______________________________________
_ParishCity_________
_________________
MothersName_____________
___________Phone(Day
)(____)________(Evenin
g)(____)_________
MothersCompleteAddress(ifdifferentthanabove)________
____________________________________
FathersName_________________________Phone(Day)(____)________(Evenin
g)(____)_________
FathersCompleteAddress(ifdifferentthanabove)____________________________
_________________
AdditionalEmergencycontactincaseyoucannotbereached(notatcamp):
__________________________________________________________
_____________________________________
Phone#
(____)_____________________Relationtoparents_________________________________
Age
#ofcampers
Cost
Total
Age0-2(nobabysitting)
__________
FREE
________
Ages2yearsoldandup
__________
$125
________
TOTALS
___
_______
________
Family Camp Page 1 of 3
-
8/14/2019 Registration Form Brochure 2010
11/12
Please
notethereare3areas
requiringsignatures!!!
DoctorsNameandClinic:____________________________
__________________________________________
DoctorsFullAddress:_______________________________
__________________________________________
DoctorsPhone#:(_____)_______
_____________
Areallimmunizationsuptodate?
Yes_____No_____
Datesoflasttetanusboosterforeachfamilymember:____________________________
____________________
___
___________________________________________
__________________________________________
Ifanyarenotuptodatepleaselist
them.______________________________________
____________________
Pleaselistanyspecialdietaryneedsforyourfamily._____________________________
____________________
___
___________________________________________
__________________________________________
Notifythestaffifanyfamilymemberisexposedtoacommun
icablediseaseduringthethreeweekspriortocamp.
Allergies/Conditions(Listwhichfamilymemberisallergictoorhas
anyofthefollowingconditions):
BeeStin
gs______
PoisonIvy______
Asthma
______
Fainting______
Penicillin______
Sulfa__
____
Seizures______
HayFever______
Other_______________________
___________________________________________
_____________________
Ifanyoftheabovewerecheckedy
es,pleasesubmitastateme
ntinspaceprovidedbelow
ofhowthefamilymember
hasbeen
treatedandwithwhatmedications.Pleasealsolist(usebackofpage3ifnecessary):
1.Anyoperationsorseriousinjuryinthepasttwoyears.
2.Medicallimitationsorneed
sthatweneedtobeaware
of.
3.Anylimitationsorneeds(learningstyles,familysituations,custodyarrangements,etc.)
Areallofyouthfamilymemberthatarecomingtocampinge
neralgoodhealthandable
toparticipateinnormal
campac
tivities?
Yes_____No_____
!!!!VERYIMPO
RTANT!!!!
YouMU
SThavewrittenverificationFROMLICENSEDME
DICALPERSONNELthatthecamperhashada
healthexaminationduringthepast
24monthsandarecordSH
OULDINCLUDE:anyph
ysicalconditionrequiring
restrictionsonparticipationincampanddescriptionsthereof,
dateofexam,andcurrenton-goingtreatmentsor
medications,andrecordshouldbesignedanddated.Ifyoualreadyhaveasportsphysicalformfromthepast24
months,
itwillalsobesufficientforverificationofcampersh
ealth,oruseourHealthEx
amWaiver(onepage
Archkck
Form)includedinthispacket.THISINFORMATIO
NMUSTBEBROUGHT
WITHYOUTHEFIRST
DAYOFCAMP.PLEASEDON
OTMAIL.(ThisInformationRequiredbyACA).
Dateofmostrecentphysicalexaminationbyalicensedmedic
aldoctor.Date:____/____/____
Dateofmostrecentphysicalexaminationbyalicensedmedic
aldoctor.Date:____/____/____
Dateofmostrecentphysicalexaminationbyalicensedmedic
aldoctor.Date:____/____/____
Dateofmostrecentphysicalexaminationbyalicensedmedic
aldoctor.Date:____/____/____
Dateofmostrecentphysicalexaminationbyalicensedmedic
aldoctor.Date:____/____/____
(Ifupcomingappointmentset,plea
senote:_____________________________________
_____________.)
Incaseofmedicalemergency,Iun
derstandthateveryeffortw
illbemadetocontactparentsorguardianofcamper.
IntheeventthatIcannotbereache
d,IherebyrequestandgivepermissiontothephysicianselectedbytheCampto
hospitalize,securepropertreatmen
tforandtoorderanesthesiaorsurgeryformychild,a
snamedherein.Insigning
thishealthform,Iherebycertifyth
attheinformationiscorrec
tandgivepermissionforthereleaseofmedical
recordstoanattendingphysicianincaseofillnessoremergen
cy.Irequestthatmychild
betransportedtoseek
neededmedicalattention.
#1SignatureofParent/Guardian___________________
________________________Date_____________
FAMILY
CAMPTEKAKWITH
A2010
PrairieStarR
anch
Page2of3ofFamilyCam
pRegistration
Family Camp Page 2 of 3
-
8/14/2019 Registration Form Brochure 2010
12/12
#1
SignatureofParent/Guardian_______________________________________
____Date_____________
#1
SignatureofAdultFamilyMember_____________
__________________________Date____________
_
#1
SignatureofAdultFamilyMember_____________
__________________________Date____________
_
Health
InsuranceCompany_______________________________________________
_______________________
Health
InsurancePolicy#___________________________
___________________________________________
_
PrimaryHealthInsuranceholder
andnameandSocialSecurity#_________________
_______________________
APhotocopyofthePrimaryHealthInsurancecardMUSTbesubmittedwiththisform.
Irequestthatmyfamily_______
_____________beallowe
dtoparticipateinthecamp
activitiesatFamilyCamp
Tekak
withaattheArchdiocesanCampinWilliamsburg,KS
.Iherebyreleaseandinde
mnifytheArchdioceseof
Kansa
sCityinKansas,itsstaff,andvolunteersfromanylia
bilityarisingfromclaimso
fanykindofnature
whatsoeverfrommychildsparticipationinthisprogram.T
heactivitiesmayincludehorsebackriding,highrope
s
challenge,powerkiting,stuntkiting,canoeing,hiking,orien
teering,rockclimbing,rap
pelling,basketball,soccer,
swimm
ing,technicaltreeclimbin
g,grouppartygames,arch
ery,volleyball,mountainb
iking,mountainboarding,
outdoorcamping,softball,numerousCatholicprayerexperiences,andotheroutdoorcampactivities.
#2
SignatureofParent/Guardian_______________________________________
____Date_____________
#2
SignatureofParent/Guardian_______________________________________
____Date_____________
#2
SignatureofAdultFamilyMember_____________
__________________________Date____________
_
#2
SignatureofAdultFamilyMember_____________
__________________________Date____________
_
PHOT
ORELEASE
IherebyauthorizetheArchdioceseOfKansasCity,anditsagentstoutilizemychilds
photographicimageforthe
specificpurposeofpublicationoftheArchdioceseOfKansasCityevents(includingpromotionalmaterials).In
giving
myconsent,Iherebyrelea
seandholdharmlesstheA
rchdioceseOfKansasCity
anditsagentsfromanyan
d
allresponsibilityorliability.IunderstandthatIwillreceive
nocompensation,shoulda
nyphotographofmebeus
ed.
#3
SignatureofParent/Guardian_______________________________________
____Date_____________
#3
SignatureofParent/Guardian_______________________________________
____Date_____________
#3
SignatureofAdultFamilyMember_____________
__________________________Date____________
_
#3
SignatureofAdultFamilyMember_____________
__________________________Date____________
_
Pleasemailto:
CampTekakwitha
ArchdioceseofKC
inKS
12615ParallelParkway
KansasCity,KS6
6109
RegistrationsMUSTBE
postmarked;handdelivered
registrationswillNOTbeaccepted.
FAMILYCAMPTEKAKWITHA2010
PrairieSta
rRanch
Page3of3ofFamilyC
ampRegistration
Family Camp Page 3 of 3