All Saints Summer Camp 2022

All Saints Summer Camp

2022
CAMPER'S INFORMATION
Camper's Name

First Name Last Name
Birth Date

Month Day Year
Age of Camper
Gender

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Camper Email
Shirt Size
Shirt Sizes
CHURCH YOU ATTEND
Cabin Friend Request * friends have to be close in age and request are not guaranteed.
Parent/Guardian Information
Name

First Name Last Name
Cell Number

Area Code Phone Number
Parent E-mail
Emergency Information
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement

We Hereby Consent

1. We consent and authorize the All Saints Summer Camp to provide treatment whether en route, on or off the campgrounds for any first aid whether routine or emergency, including, without limitation, injury, illness, choking, etc.

2. We and each of us consent and authorize All Saints Summer Camp instructors to provide treatment, including cardiopulmonary resuscitation (CPR) in the event of a water sports accident or other need.

3. If we parents/guardians cannot be reached in case our child had an emergency or other medical need, we and each of us hereby appoints, authorizes, and constitutes the All Saints Summer Camp Director, Camp Health Officer/ Nurse/ Doctor, or other duly authorized staff members to act in our behalf as parents to authorize and consent to medical treatment for our child/ren named herein:

including authorizing surgery. In case of need, we authorize any family or specialist physician, dentist, or other licensed healthcare professionals, and also any licensed health care facility to provide any and all necessary treatment to our child.

The below consent and authorization includes routine, emergency, inpatient, and outpatient care. Any health care professional or health care facility is authorized to accept and rely on the All Saints Summer Camp Staff's representation if we cannot be reached. The original form shall be displayed to a health care provider, but this original shall remain in the custody of the Camp Director.

In addition, I agree that in the case of a health or accident emergency, or any other situation which might arise en route to and from camp, or while attending camp, that none of the facilitators, staff or sponsors of the All Saints Summer Camp including but not restricted to The Orthodox Church in America, The Diocese of the South, St. Seraphim Orthodox Cathedral, Holy Nativity of the Lord Mission or its staff, volunteers or representatives will be held liable in any way.

The undersigned acknowledges that, during participation at All Saints Summer Camp, at the site of Akiva Camp, and at other facilities used for supervised camp-related activities, certain risks and dangers may occur. These include, but are not limited to, loss or damage to personal property, physical or psychological damages and/or injury, not excluding fatality, due to accidents, which may occur. I also acknowledge that participants may be transported off the camp for supervised camp-related activities.

In consideration, and as a part of the right to participate in this All Saints Summer Camp Program, I have and do hereby assume all of the above risks and any other ordinary risk incidental to the nature of these activities which are not specifically foreseeable, and will not hold liable the Orthodox Church in America, the Diocese of the South, All Saints Summer Camp, St. Seraphim Orthodox Cathedral, Holy Nativity of the Lord Mission, Volunteers, Agents or Participants. I agree that any person/s providing service to the Camp, harmless from any and all liability actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss, which may arise in connection with any participant's activities and participation in All Saints Winter Camp.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature
Date

Month Day Year
Date
Medical Dispensation

We have indicated that our child, will be using medication while he/she is attending All Saints Summer Camp. Please list below in the appropriate columns all Prescription and Over-the-Counter Medication information which the participant may require during the Camp:
YOUTH INHALER or EPIPEN

If a Youth Participant uses an inhaler to treat asthma, or carries an EpiPen:

Please Note! If this youth participant has your permission to self-medicate with any or all of the above described prescriptions or over the counter medications, or if a parent will be present and wishes to retain this responsibility, please clearly indicate above in the "Given By" Column. Otherwise, all listed medications will be collected at the beginning of the summer camp to be safely stored and administered by the Camp's Designated Nursing Staff. All medications need to be brought to the camp and presented to Staff in original packaging and prescription bottles. Signature of Parent/s or Legal Guardian
I wish the asthma inhaler or epi-pen to be with my Youth Participant at all times. I wish the asthma inhaler or epi-pen to be kept with the Youth Retreat Health Officer/Nurse.
Payment due at time of Registration

Camp Tuition is $305 and due by June 1st. After June 1st, there will be a $50 cancelation fee.

We will not be accepting tuition at camp.

Payment can be made using one of these four options:

1. Mail a check made out to Holy Nativity, 588 Oneonta St., Shreveport, LA 71106

2. Google Pay - pay.google.com and send money to AllSaintsSummerCamp@gmail. com

3. Venmo - @allsaintssummercamp-132

4. Paypal - For a fee of $10, making All Saints Camp Fee $315 you can add to cart and pay using paypal @ allsaintssummercamp@gmail.com
Should be Empty:

All Saints Summer Camp

Medical Dispensation