INSURANCE INFORMATION **

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INSURANCE INFORMATION **

  1. 1. 2005 SPRING FAMILY CAMP APPLICATION May 13-15, 2005 Camp Barney Medintz, Cleveland, GA FALL FAMILY CAMP REGISTRATION October 13 – 15, 2006  The Retreat Center at Ramah Darom Camper’s Name Date of Birth: Age __ Sex: Family’s Address: City/State: ________________________________________________Zip: _____________________________ Home Phone:____________________________ Email Address:_____________________________________ Parent(s)/Guardian(s)’ Names: Father’s Place of Employment_________________________________ Work Phone: (____)_______________ Mother’s Place of Employment________________________________ Work Phone: (____)_______________ Has your family previously attended Camp Kudzu Family Camp? If yes, list years attended Did your child attend Summer Camp 2006? ____________ If no, list reason_____________________________ Additional family members attending Family Camp Weekend (limited to immediate family members only): Name_______________________________ Relationship to camper __________________ Age _____ Sex ___ Name_______________________________ Relationship to camper __________________ Age _____ Sex ___ Name_______________________________ Relationship to camper __________________ Age _____ Sex ___ Name_______________________________ Relationship to camper __________________ Age _____ Sex ___ Name_______________________________ Relationship to camper __________________ Age _____ Sex ___  I am a single parent, and my family is willing to share a cabin with another single parent family of the same sex.  Please contact me regarding a scholarship for my family to attend family camp. (The cost is $300 per family. Payment should NOT be mailed with these forms.)  Please indicate the number and sizes of t-shirts for your family: Child: S____ M____ L____ / Adult: S____ M____ L____ XL____ XXL____ Fax completed application to 404.250.1812 or mail to 4279 Roswell Road, Suite 102, Box 254, Atlanta, GA 30342 1
  2. 2. Parent/Guardian’s Signature: _______ Date: FALL FAMILY CAMP REGISTRATION October 13 – 15, 2006 The Retreat Center at Ramah Darom CAMPER INFORMATION Camper Name: ________________________________________ Date Diabetes Diagnosed _______________ Camper’s restrictions or special needs while at camp: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ___ PHYSICIAN INFORMATION (Please list both an endocrinologist and a pediatrician) Endocrinologist:_____________________________________________Phone:__________________________ Pediatrician:________________________________________________Phone:__________________________ INSURANCE INFORMATION ** Medical Insurance Company: Policyholder/Subscriber’s Name: ______ Identification number:________________________________________________________________________ ** (Please include a photocopy, front and back, of the insurance card) EMERGENCY INFORMATION In case of family emergency, please notify: Name: ______ Relationship: Day phone: ( ) ___ Evening phone: ( ) ___ Mobile phone: ( ) ______ If anyone in the family has a special dietary need (other than diabetes) (e.g., food allergy, vegetarian diet), please list: Name:____________________________________________________________________________________ Name:____________________________________________________________________________________ Additional information that we should know about your family including special needs and requests: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Fax completed application to 404.250.1812 or mail to 4279 Roswell Road, Suite 102, Box 254, Atlanta, GA 30342 2
  3. 3. _________________________________________________________________________________________ ______ _________________________________________________________________________________________ _ FALL FAMILY CAMP REGISTRATION October 13 – 15, 2006 The Retreat Center at Ramah Darom CONSENT FORM The following consent agreement must be signed in order for your family to attend the Camp Kudzu Fall Family Camp Weekend. Your signature below indicates approval of the following: 1. In the event my family participates in the 2006 Camp Kudzu Fall Family Camp Weekend, I hereby waive, release and discharge any and all claims for damages for death, personal injury or property damage which I may have, or which may hereafter accrue to me, as a result of my family’s participation in the Camp’s activities. This release is intended to discharge in advance Camp Kudzu and all of its agents, representatives, volunteers and employees from any and all liability, claims, costs, expenses and/or damages (collectively referred to as liability) arising out of or connected in any way with my family’s participation in the activities of Camp, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above. I further understand that serious accidents occasionally occur during Camp activities, and that participants in Camp activities may sustain mortal or serious personal injuries and/or property damage as a consequence thereof. Knowing risks of camp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence or carelessness) might otherwise be liable to my child(ren) or to me (or my heirs or assigns) for damages. I further agree to indemnify and hold harmless Camp Kudzu and all of its agents, representatives, volunteers and employees, in the event any other person or entity, other than the undersigned, brings an action for the death or personal injuries of myself or my child(ren), as a result of my or my child(ren)’s participation in the Camp’s activities. 2. Camp Kudzu accepts no responsibility for the loss, damage or theft of personal property. 3. In case of medical and/or surgical emergency, you authorize Camp Kudzu’s medical staff to render to you and your child(ren) and to arrange for you and your child(ren) to receive any X-rays, anesthetic, medical, dental, surgical diagnosis, treatment and hospital care which is deemed advisable by and is rendered under, the supervision of any physician, dentist or surgeon licensed to practice in the state of Georgia. 4. I accept responsibility for routine medical care for my child(ren) with diabetes. 5. Camp Kudzu and its representatives have full permission and authority to photograph and record my family and to use, publish and release for publication such photographs, voice recordings and images that pertain to the lawful programs and activities of the Camp. Such use shall include, but not be limited to, display of pictures on Camp Kudzu’s website, advertisement and promotion on television, radio, newspaper, magazine, the internet, promotional film, video, posters, fliers, etc. Additionally, Camp Kudzu and its representatives have permission to identify my family in such photographs and images and use my family’s name as it relates to our participation in Camp programs. 6. I hereby accept responsibility for my child(ren) while attending the 2006 Camp Kudzu Fall Family Camp Weekend. My child(ren) have permission to engage in all activities, except as noted by me, and I accept responsibility for them during those activities. Parent/Guardian’s Signature :_________________________________________________Date: _________________ Printed name: _____________ Relationship to Child(ren): ______________________ Fax completed application to 404.250.1812 or mail to 4279 Roswell Road, Suite 102, Box 254, Atlanta, GA 30342 3
  4. 4. Parent/Guardian’s Signature :_________________________________________________Date: _________________ Printed name: _______ Relationship to Child(ren): __ All adults in attendance must sign consent Fax completed application to 404.250.1812 or mail to 4279 Roswell Road, Suite 102, Box 254, Atlanta, GA 30342 4

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