Intrepid Camp - Individual Registration

Intrepid Wildfire Camp provides the opportunity for you or your youth group to serve in the mission field of Central Missouri. Youth will be spending their days serving the community and their nights listening to powerful Christian speakers, swimming, playing sports, and relaxing on the beautiful campus of Central Methodist University.  Come for a week you will never forget!

Tell us about your camper
*Camper First Name
*Camper Last Name
*Are you a counselor?
Yes
No
Camper Contact Information

If the camper is under 18 years of age, contact information for the camper's parent or legal guardian must be entered.

*First Name
*Last Name
*Address 2
*City
*State
*Zip
*Phone
*Email
*When is your birthday?

Enter as 00/00/0000. Example: 12/07/1980

*What school grade will you start in the fall?
*Gender
Male
Female
*What is your T-Shirt Size?
*Are you registering for Intrepid as part of a group?
Yes
No
*Church

If you're registering as part of a church group, select which church you'll be attending with.

*Are you a counselor?
Yes
No
*Individual Registration Fee ($300)
Pick-Up Information
*What is the full name of the person authorized to pick-up the camper?
*Cell phone number of the authorized primary pick-up
*Please enter a family code word. This will help us insure your child's safety during pickup.
Medical Information
*Are you allergic to any medications?
Yes
No
Please list the medications you are allergic to and give as much detail as possible.
*Allergies
Check the boxes that apply to your camper or check "None of the Above"
Camper is allergic to insect stings
Camper is allergic to Poison Ivy, Poison Oak or Sumac
Camper is allergic to Shellfish, Eggs, or Milk
Camper is allergic to other foods
Gluten-free diet
Camper is allergic to latex bandaids, gloves, or balloons
None of the above
*Explain:
*Health History

Check the boxes that apply to your camper, or select "None of the Above"

Asthma
ADD / ADHD
Sleep Walking
Night Terrors
Eczema
Enuresis (bed wetting)
Tourette Syndrome
Hypoglycemia
Migraines
Asperger Syndrome
Down Syndrome
Physical Disability (muscular/coordination)
Blind / Legally Blind
Celiac Disease
Knee Problems (total knee replacmement, ACL, etc.)
Seizure Disorder
Autism
Hard of Hearing/Deaf
Back or neck injury (Previous)
Cancer
Cardiac Issues / Hypertension
Other concerns/disorders
None of the above
*Explain:
*Has your camper been hospitalized in the last year?
Yes
No
*Hospitalization - Details:
*Are there any activities your camper is restricted from doing?
Yes
No
*What are the restrictions and why?
*Medical History - Social Concerns
Depression
Suicidal Tendencies
Physical Abuse
Sexual Abuse
Emotional Abuse
Drug and Alcohol Abuse
Self-Mutilating Behavior
Anxiety
Bi-polar/Psycho-social disorder
Gender Identity
None of the Above
*Explain:
Emergency Contact
*Emergency Contact #1 - Name
*Emergency Contact #1 - Phone
Emergency Contact #2 - Name
Emergency Contact #2 - Phone
Medications

Medicine will not be dispensed unless the following guidelines are met:

All medications, except inhalers and EPI pens, are turned into the Camp First Responder at check-in. Please note, all prescriptions medications must be sent in the original containers with the camper's name and prescribing physician's directions for use clearly marked on the label. Over-the-counter medications must also be in their original containers. Medication can only be given according to how it is prescribed on the prescription or original over-the-conter container. If your child takes medication different than what is printed on his/her prescription container or over-the-counter medication container, a statement from the child's primary physician must accompany the medicine, no exceptions. When preparing for camp, place all medication containers in a single Zip-lock bag with the camper's name on the outside. Each site will have a Camp First Responder that will distribute medications.

*Will the camper be taking medications while at camp?
Yes
No
*Medication Name
*Strength/Dosage
*When does the medication need to be administered?
Breakfast
Lunch
Dinner
Bedtime
As needed
Special Instructions or Comments
*Medication Name
*Strength/Dosage
*When does the medication need to be administered?
Breakfast
Lunch
Dinner
Bedtime
As needed
Special Instructions or Comments
*Medication Name
*Strength/Dosage
*When does the medication need to be administered?
Breakfast
Lunch
Dinner
Bedtime
As needed
Special Instructions or Comments
*Medication Name
*Strength/Dosage
*When does the medication need to be administered?
Breakfast
Lunch
Dinner
Bedtime
As needed
Special Instructions or Comments
*Medication Name
*Strength/Dosage
*When does the medication need to be administered?
Breakfast
Lunch
Dinner
Bedtime
As needed
Special Instructions or Comments
*Medication Name
*Strength/Dosage
*When does the medication need to be administered?
Breakfast
Lunch
Dinner
Bedtime
As needed
Special Instructions or Comments
Immunizations

Please indicate date(s) of all Attendee immunizations. State law requires an accurate record of your attendee's current immunization status. Attendees will not be allowed to participate in activities without a completed record. It may not be necessary to use all boxes provided below.

I have religious / personal objections, and my child is in good health.
Tetanus - Diptheria - Pertussin
*Date of Vaccination #1
Date of Vaccination #2
Date of Vaccination #3
Measles, Mumps, Rubella
*Date of Vaccination #1
Date of Vaccination #2
Date of Vaccination #3
Hepatitis B
*Date of Vaccination #1
Date of Vaccination #2
Date of Vaccination #3
Chicken Pox
*Date of Vaccination #1
Date of Vaccination #2
Date of Vaccination #3
Liability Release

Release of Liability

By signing this Consent/Release Form, I acknowledge that ministries, programs and activities conducted by the Missouri Annual Conference of the United Methodist Church, the Missouri United Methodist Camping and Retreat Ministries and their related and affiliated organizations (collectively, the 'Conference'), especially, but not limited to, the Ignite mobile camps, Infuse community/residential camps, Intrepid Wildfire Camps, Spark Mini Mobile Camps, and Impact mission camps (individually or collectively, the "Camp(s)"), involve a certain amount of risk to individuals participating. Activities may include strenuous or moderately strenuous physical activities including, but not limited to climbing, swimming, boating, physically active games, jumping and manual labor. With this information, I acknowledge and consent to my or my minor child's participation in the Camp(s) for which they have enrolled. I further acknowledge and consent to any organized travel by van or bus as part of the activities conducted during the Camp(s).

Acknowledging the activities involved, I hereby release and hold harmless the Conference, its agencies, related organizations, employees, directors, counselors, leadership, volunteers and members from any and all liability that may arise as a result of my or my child's participation in the Camps except in the case of gross negligence or intentional misconduct.


Medical Consent for Treatment

During the Camp(s) in which I or my child are participating, I hereby authorize the adult camp director(s) and/or adult counselors designated to lead that camp to consent to any necessary examination, anesthetic, medical diagnoses or hospital care for my minor child named below. I understand that I will be notified as soon as possible in the event of an emergency. I also understand that designated volunteer first responders who are may or may not be professionally trained doctors or nurses may offer First Aid in the event of an accident.


Consent for Use of Photographs and/or Video

I give permission for the Conference to use images, pictures and/or video of myself or my child/children taken during the Camps in which they are participating. Such uses will only include the use of such images, photos or videos in electronic or printed promotional materials, on the Conference's website, the Missouri Methodist publication or as a display or presentation during the Missouri Annual Conference Sessions or other meetings held by the Conference.

*Signature
Medical Insurance Information
*Do you have health insurance?
Yes
No
*Health Insurance Provider
*Medicaid or Insurance Policy or ID Number
*Group Number
*Policy Holder's Name
Primary Physician's Name
Physician's Phone
Medical History Release

Release and Consent for Medical Treatment

I, the undersigned, hereby give my consent for my child to participate in the Missouri Annual Conference Camping event for which he/she is enrolled. I give my consent for my child to receive medications listed and properly labeled according to the instructions given by myself or the prescribing physician for any over-the-counter (OTC) drug and/or given by the prescribing physician for prescriptions medications. I understand that the information is confidential and only camp personnel, needing to know, have access to this information. I agree to coordinate and work with camp personnel and the prescriber if questions arise.

I understand that I may cancel this request at any time, and/or retrieve the medication from the camp at any time.

In the event that my child is injured or becomes ill while participating in an activity related to the event for which he/she is enrolled, I hereby give permission for reasonable and necessary medical care and treatment to be administered to my child by the camp health supervisor and/or physician selected by the camp director/health supervisor.

I authorize the event's First Responders to administer common over-the-counter medications (including ear drops, antacids, throat lozenges, pseudophedrine, anti-itch lotion, loratadine/other antihistamine, cough medicine/drops, acetaminophen, and ibuprofen) as necessary, unless an allergy or intollerance has been previously noted in my child's medical form.

All medications, except inhalers and EPI pens, are turned into the Camp Director at check-in. Please note, all prescriptions medications must be sent in the original containers with the camper's name and prescribing physician's directions for use clearly marked on the label. Over-the-counter medications must also be in their original containers. Medication can only be given according to how it is prescribed on the prescription or original over-the-conter container. If your child takes medication different than what is printed on his/her prescription container or over-the-counter medication container, a statement from the child's primary physician must accompany the medicine, no exceptions. When preparing for camp, place all medication containers in a single Zip-lock bag with the camper's name on the outside. Each site will have a health supervisor that will distribute medications.

*Signature
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