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2017 Camp EXP Registration
General Registration Info

REGISTRATION IS NOT COMPLETE UNTIL PAYMENT IS MADE. CAMP IS $400. Please write a check to Grace Church and drop off to the office. Put the student's full name in the Memo line.

Email address
Participant Full Name
Your answer
Participant Gender
Participant Date of Birth
MM
/
DD
/
YYYY
Participant Age (as of August 1, 2017)
Your answer
Participant Grade (as of August 1, 2017)
Your answer
Participant T-shirt Size
Participant Small Group (as of August 1, 2017)
Your answer
Parent/Guardian Full Name
Your answer
Parent/Guardian Email
Your answer
Parent/Guardian Phone Number
Your answer
Liability Release Form
In consideration for being accepted for participation in Camp EXP (trip or activity), date(s) July 31 – August 4, 2017, I do by typing my name below hereby release, forever discharge and agree to hold harmless GRACE CHURCH OF CHAPEL HILL, NC, GRACE CHURCH OF SOUTHERN PINES, VALLEY COMMUNITY CHURCH, VA, LIVING WAY CHURCH, GRENSBORO, NC, and GRACELIFE CHURCH, COLUMBIA, SC and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above-described trip or activity including recreation and work activities. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.

The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as theretofore described, the undersigned agrees to hold harmless and indemnify said church, its directors, employees and agents form any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical are on behalf of the participant.

Parent/ Legal Guardian Full Name
Your answer
Participant Full Name
Your answer
Participant Insurance Company
Your answer
Participant Policy Number
Your answer
Emergency Contact Information
Full Name + Relation to student
Your answer
Address: Street Name, City, State, Zip Code
Your answer
Home, Cell, and Work Phone
Your answer
Ropes Course Option
Ropes Course Policy

-All participants using the Odyssey High ropes or Low ropes Initiatives must complete, sign and provide WOCC the appropriate release form.
-All participants must 14 years of age to participate on the Odyssey High ropes course.
-Any Participant under 18 years of age must provide a signed custodial guardian permission form.
-All sessions must be facilitated by certified WOCC staff.
-No guests should be on or attempt to access any of the elements or ropes course without WOCC staff supervision.
-All activities are challenge by choice.

Consent for ropes course?
EXP Medication Form (General Information)
Physician Full Name
Your answer
Physician Telephone Number
Your answer
Parent/Legal Guardian Full Name (typing name here certifies that all information is complete and accurate):
Your answer
EXP Medication Form (Medication 1)
Please furnish medication in the original container.
Medication (type "N/A" if there is no medication to report for this section)
Your answer
Dosage
Your answer
Route
Your answer
Frequency
Your answer
Type of medication
Specify other type of medication
Your answer
Significant Information (side effects, adverse & omission reactions):
Your answer
Contradictions for Administration
Your answer
Allergies and important medical notes
Your answer
Administration
EXP Medication Form (Medication 2)
Please furnish medication in the original container
Medication (type "N/A" if there is no medication to report for this section)
Your answer
Dosage
Your answer
Route
Your answer
Frequency
Your answer
Type of medication
Specify other type of medication
Your answer
Significant Information (side effects, adverse & omission reactions):
Your answer
Contradictions for Administration
Your answer
Allergies and important medical notes
Your answer
Administration
EXP Medication Form (Medication 3)
Please furnish medication in the original container
Medication (type "N/A" if there is no medication to report for this section)
Your answer
Dosage
Your answer
Route
Your answer
Frequency
Your answer
Type of medication
Specify other type of medication
Your answer
Significant Information (side effects, adverse & omission reactions):
Your answer
Contraindications for Administration
Your answer
Allergies and important medical notes
Your answer
Administration
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