The camper application form provides contact and medical information for a camper attending Camp Rockfish, including the camper's name, address, parent/guardian details, insurance information, medical history, medications, and a health care provider authorization signed by a parent or guardian. The form also lists the camp sessions available and includes a section for the camper's parent/guardian to indicate which sessions they are signing up for.

1. Camp Rockfish Application
Summer 2012
Mail to: 226 Camp Rockfish Rd, Parkton, NC 28371 Attn: Resident Camp Registration
Phone # (910) 425-3529 Fax # (910) 875- 6177 Website: www.camprockfish.org
Campers Name________________________________ Preferred Name_________________ Male__ Female__
Birthday (M/D/Y)_________________ Grade entering ___________ Age during camp_______________
Child’s Mailing Address________________________________City____________________State____ Zip _______
Child’s Physical Address_______________________________City____________________State____ Zip ______
(if different from above)
E-Mail for updated Rockfish information ________________________________________________________
Please Indicate with whom camper lives: __Both Parents __Mother __Father __Guardian
Parents are: __Married __Separated __Divorced __Single __Re-married __Widowed
Mother/Guardian #1_________________________________ Home Phone (___)__________________________
Cell Phone #(___)_________________________ Work Phone#_____________________
Home Adress_____________________________________City________________State_____ Zip_____________
Father/Guardian #2_________________________________ Home Phone (___)__________________________
Cell Phone # (___)_________________________ Work Phone # (___)_____________________
Home Adress__________________________________City__________________State_____Zip_______________
Emergency Contact (in case we cannot get in touch with parents/guardians)
1. ________________________ Relationship to camper __________________ Daytime Phone #(___)______________
Address __________________________City _______________State _____Zip_______Work # (___)______________
2._________________________ Relationship to camper __________________ Daytime Phone #(___)______________
Address __________________________City _______________State _____Zip_______Work # (___)______________
Insurance Carrier:_____________________________________ Subscriber: _________________________________
Subscriber Number: _________________________________
Sheltermate Request _______________________________________________
Have you been to Camp Rockfish before __Yes __No If yes, what years?________________
How did you hear about Camp Rockfish? __Internet __Camp Fair __Friend __Former Camper/Staff
__ Print __Ad __Sibling __Attended __Other______________________
___ I have included the $100/$50 deposit towards my camper’s overall balance.
___ I have included the $100/$50 deposit plus an additional $______ towards my camper’s
overall balance.
___ I have included $______ towards my camper’s store account. TOTAL ($):_______
With registration by mail, we encourage a check payment. However, if needed a credit card
payment can be made once forms are received. A Rockfish staff member will contact you for
credit card information to complete the registration process.
If you have any questions, our office can be contacted by phone at (910)425-3529 or by email at
info@camprockfish.org.
All camp fees are due by June 1, 2012.

2. Camp Session Sign up
The chart on the following page shows all programs that we have available for the summer.
Within the chart, please check the white box corresponding with the camp of your choice.
When turning in this application, please include the initial deposit of $100 for Resident
Camp and $50 for Day Camp. This deposit will go towards your overall camp balance.
There is also the option of providing your camper with money for the camp store. When your
application and fee have been processed, you will receive a confirmation letter or email
including our parent pack. If you have any further questions, please call (910) 425-3529 ext.
23.
All paperwork is due on the registration day for your camp.
Chart Key:
July 29 – Aug. 4
June 10-16
June 17-23
June 24-30
Aug. 12-18
July 15-21 - White boxes indicate which
July 22-28
Aug. 5-11
July 8-14
July 1-7
Resident Camp weeks of programs are available.
- Gray Boxes indicate which
weeks programs are closed.
Traditional
Survivor Program Prices:
Night Owls Traditional - $445
Roller Coaster Survivor - $465
Extreme Explorers Night Owls - $450
Outbounders Roller Coaster - $750
Water Extreme Explorers - $625
Kayak Venture Outbounders - $720
Water - $455
W.Y.L.D. Bunch
Kayak Venture - $490
Footprints
W.Y.L.D. Bunch - $990
Family Camp
Mini - $205
Day - $150
June 17-20
June 20-23
July 15-18
July 18-21
Mini Camp
July 30 – Aug. 3
June 11-15
June 18-22
June 25-29
Aug. 13-17
July 16-20
July 23-27
Aug. 6-10
July 9-13
July 2-6
Day Camp
I verify that all of the above information is true and correct to the best of my knowledge.
Signature_____________________________________________________________________ Date______________
For office use only: / / __ Balance$_________ Date Deposit Received: ________

3. CAMPER HEALTH Dates will attend camp: from ______________to_____________
Camper Name ______________________________________________________________________ (For Camp Use) Cabin or Group____________________ (For Camp Use) Session Code(s): ________________
Month/Day/Year Month/Day/Year
HISTORY FORM 1 Camper Name: _____________________________________________________________
First Middle Last
Developed and reviewed by: American Camp Association, Male Female Birth Date ____________ Age on arrival at camp: ________
American Academy of Pediatrics Council on School Health, & Month/Day/Year
Association of Camp Nurses
To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.
First
Mail this form to the address below by _______ (date)
1) Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy.
2) Send the original, signed FORM 1 to camp by the requested date.
3) Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the
copy of FORM 1 with FORM 2 to your child’s health-care provider for review and completion.
4) After it has been completed and signed by your child’s health-care provider, return FORM 2 to
camp by the requested date.
Camper Home Address: ______________________________________________________________________________________________________
Street Address City State Zip Code
Parent/guardian with legal custody to be contacted in case of illness or injury:
Relationship
Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________
Email: _______________________
Middle
Home Address: _____________________________________________________________________________________________________________
(If different from above) Street Address City State Zip Code
Second parent/guardian or other emergency contact:
Relationship
Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________
Email: _______________________
Additional contact in event parent(s)/guardian(s) can not be reached:
Relationship
Name(s): __________________________ to Camper: ________________ Preferred Phones: (______) ________________(______)_________________
Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other
(Please describe below what the camper is allergic to and the reaction seen.)
Last
Diet, Nutrition: This camper eats a regular diet. This camper eats a regular vegetarian diet.
This camper has special food needs. (Please describe below.)
Restrictions: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or
adaptations. (Please describe below.)
Medical Insurance Information:
This camper is covered by family medical/hospital insurance Yes No
Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company______________________________ Policy Number___________________________
Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in
all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests,
and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on
this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a
copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Signature of Custodial Relationship
Parent/Guardian __________________________________________________________________Date: to Camper: _______________________
If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/4

4. CAMPER HEALTH HISTORY FORM 1
Camper Name: ________________________________________________
First Middle Last
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on Birth Date: ____________
School Health, & Association of Camp Nurses Month/Day/Year
Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms
from health-care providers or state or local government are acceptable; please attach to this form.
Immunization Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Most Recent Dose
Month/Year Month/Year Month/Year Month/Year Month/Year Month/Year
Diptheria, tetanus, pertussis
(DTaP) or (TdaP)
Tetanus booster
(dT) or (TdaP)
Mumps, measles, rubella
(MMR)
Polio
(IPV)
Haemophilus influenzae type B
(HIB)
Pneumococcal
(PCV)
Hepatitis B
Hepatitis A
Varicella Had chicken pox
(chicken pox) Date:
Meningococcal meningitis
(MCV4)
Tuberculosis (TB) test Date: Negative Positive
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not
being fully immunized.
Signature of Custodial Relationship
Parent/Guardian: ______________________________________________________________Date: to Camper: __________________________
Medication: This camper will not take any daily medications while attending camp.
This camper will take the following daily medication(s) while at camp:
"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp
instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper’s
name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Name of medication Date started Reason for taking it When it is given Amount or dose given How it is given
Breakfast
Lunch
Dinner
Bedtime
Other time:_____________
Breakfast
Lunch
Dinner
Bedtime
Other time:_____________
Breakfast
Lunch
Dinner
Bedtime
Other time:_____________
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.
Cross out those the camper should not be given.
Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin)
Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed)
Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin)
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM)
Sore throat spray Generic cough drops
Lice shampoo or cream (Nix or Elimite) Antibiotic cream
Calamine lotion Aloe
Laxatives for constipation (Ex-Lax) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
Copyright 2008 by American Camping Association, Inc. Page 2/4 Rev. 1/2007 LEE/EAW

5. CAMPER HEALTH HISTORY FORM 1
Camper Name: ________________________________________________
First Middle Last
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on Birth Date: ____________
School Health, & Association of Camp Nurses Month/Day/Year
General Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.
Has/does the camper:
1. Ever been hospitalized? …………………………. Yes No 11. Had fainting or dizziness? ..................................................... Yes No
2. Ever had surgery? .............................. …………. Yes No 12. Passed out/had chest pain during exercise? ….……………. Yes No
3. Have recurrent/chronic illnesses? .......……….… Yes No 13. Had mononucleosis ("mono") during the past 12 months?... Yes No
4. Had a recent infectious disease? ....... …………. Yes No 14. If female, have problems with periods/menstruation?.…….. Yes No
5. Had a recent injury? ........................... …………. Yes No 15. Have problems with falling asleep/sleepwalking? ............... Yes No
6. Had asthma/wheezing/shortness of breath?...... Yes No 16. Ever had back/joint problems?…….………...……………...... Yes No
7. Have diabetes? .................................. …………. Yes No 17. Have a history of bedwetting?………………….……………... Yes No
8. Had seizures? .................................................... Yes No 18. Have problems with diarrhea/constipation?……………….... Yes No
9. Had headaches? …………………………………. Yes No 19. Have any skin problems?…………………….......................... Yes No
10. Wear glasses, contacts, or protective eyewear? Yes No 20. Traveled outside the country in the past 9 months?.............. Yes No
Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited
and dates of travel.
Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.
Has the camper:
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ………………………........ Yes No
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……............................................................................. Yes No
3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. Yes No
4. Had a significant life event that continues to affect the camper’s life?...................................................................................................... Yes No
(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
Health-Care Providers:
Name of camper’s primary doctor(s): ____________________________________________________ Phone: (________) _______________________
Name of dentist(s):___________________________________________________________________ Phone: (________) _______________________
Name of orthodontist(s):_______________________________________________________________ Phone: (________) _______________________
What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important or
that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.
Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.
Copyright 2008 by American Camping Association, Inc. Page 3/4 Rev. 1/2007 LEE/EAW

6. CAMPER HEALTH HISTORY FORM 1
Camper Name: ________________________________________________
First Middle Last
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on Birth Date: ____________
School Health, & Association of Camp Nurses Month/Day/Year
Individual Health Record (For Camp Use Only)
Initial Screening Date/Time: _________ Initials: ____________
Screening has been conducted according to camp protocol and significant findings noted as follows:
A. Any signs/symptoms of illness or injury upon arrival?........................ No Yes as noted below
B. History of exposure to communicable disease?.................................. No Yes as noted below
C. Additions or corrections to information on this health history?............ No Yes as noted below
D. Medication given to health-care staff?.................................................. No Yes as noted below
E. Any signs/symptoms of head lice?...................................................... No Yes as noted below
Provider notes: (date/time/initial all entries) _____________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Exit Note: Check one of the following:
Left camp this day with no reported illness or injury symptoms.
Left camp this day with the following problem/concern:
_____________________________________
________________________________________________________________________________________________________________
This person was told about the problem and instructed about follow-up as noted above: __________________________________________
Date/Time: ___________ Initials: __________
Copyright 2008 by American Camping Association, Inc. Page 4/4 Rev. 1/2007 LEE/EAW

7. Camper Name ______________________________________________________________________ (For Camp Use) Cabin or Group____________________ (For Camp Use) Session Code(s): ________________
CAMPER HEALTH-CARE RECOMMENDATIONS To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your
by LICENSED MEDICAL PERSONNEL FORM 2 completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.
Developed and reviewed by: American Camp Association, Dates will attend camp: from ______________to_____________
American Academy of Pediatrics Council on School Health, &
Month/Day/Year Month/Day/Year
Association of Camp Nurses
Camper Name: _____________________________________________________________
First Middle Last
Male Female Birth Date ____________ Age on arrival at camp ________
First
Mail this form to the address below by _______ (date) Month/Day/Year
Camper home address: ________________________________________________________
____________________________________________________________________________
City State Zip Code
Custodial parent(s)/guardian(s) phone: (_______)______________ (_______)____________
Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.
The following non-prescription medications are Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all
commonly stocked in camp Health Centers and are remaining sections of this form (FORM 2). Attach additional information if needed.
used on an as needed basis to manage illness and
injury. Medical personnel: Cross out those items the
Physical exam done today: Yes No (If “No,” date of last physical: ___________)
camper should not be given. Month/Day/Year
ACA accreditation standards specify physical exam within last 24 months.
Middle
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Phenylephrine (Sudafed PE) Weight: _______ lbs Height: _____ft_____in Blood Pressure_______/_______
Pseudoephedrine (Sudafed)
Chlorpheneramine maleate Allergies: No Known Allergies
Guaifenesin
Dextromethorphan To foods (list):
Diphenhydramine (Benadryl)
Generic cough drops To medications: (list):
Chloraseptic (Sore throat spray)
Lice shampoo or scabies cream (Nix or Elimite) To the environment (insect stings, hay fever, etc.– list):
Calamine lotion
Bismuth subsalicylate (Pepto-Bismol) Other allergies: (list):
Laxatives for constipation (Ex-Lax)
Hydrocortisone 1% cream Describe previous reactions:
Topical antibiotic cream
Calamine lotion
Last
Aloe
Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions:(describe below)
The camper is undergoing treatment at this time for the following conditions: (describe below) None.
Medication: No daily medications. Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below)
Other treatments/therapies to be continued at camp: (describe below) None needed.
Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes
If you answered “Yes” to the question above, what do you recommend? (describe below—attach additional information if needed)
“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s
parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as
noted above.)
Name of licensed provider (please print): __________________________________Signature: _________________________________Title: _________
Office Address_____________________________________________________________________________________________________________
Street City State Zip Code
Telephone: (________)_____________________ Date:_______________________
Copyright 2008 by American Camping Association, Inc. Rev. 2/07 LEE/EAW

8. ADVENTURE WAIVER
Rockfish Camp & Retreat Center
PARTICIPATION ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS and
RELEASE AND INDEMNITY AGREEMENT
In consideration of the services of Camp Rockfish, and its chartering organization, NC United Methodist Camp & Retreat Ministries,
INC., and each of their respective agents, employees, officers, directors, trustees, affiliates, representatives, independent contractors,
volunteers (including consulting physicians), and any and all other persons or entities acting under their direction and control
associated with them (collectively referred to as “ROCKFISH”), participant (and parent or guardian of a participant) acknowledges
and agrees as follows:
ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS
I understand that participant and parents share the responsibility for participants’ safety, for managing the risks and for determining
the participant’s suitability for the program in which he/she will participate. I have accurately completed any required ROCKFISH
application and medical forms and have reviewed all ROCKFISH program information provided to me. I agree to have my child obey all
ROCKFISH rules, regulation and policies. My child has no mental or physical problems or limitations that might affect my child’s ability to
participate that have not been disclosed to ROCKFISH in writing, I have had the opportunity to ask question about the program activities and
the risks of the program in which my child will participate.
I understand and acknowledge that the program(s) in which my child will participate has risks and it is impossible to anticipate
every activity in which my child will engage. The activities will depend on the program but may be physically strenuous. These activities
may be instructional, educational, or adventurous and may include but are not limited to: hiking, archery, BB guns, skate park, camping,
including cooking over stoves, open fires or by other means; ropes and/or challenge courses (traversing ropes suspended off the ground,
potentially at great heights, zip lines and other such activities); physical problem-solving activities; rock, wall or tower climbing; repelling;
water activities including rafting, canoeing, kayaking, or swimming; vehicle travel, and rescue scenarios (real or simulated). I understand that
my child may engage in other activities not listed above. Activities may take place in North Carolina or the United States. Participants may
also be in urban or other areas with exposure to individuals who are not under ROCKFISH’s supervisions or control. The planned program
may be modified for any number of reasons, including convenience, weather, emergencies or unexpected conditions.
It is impossible to know or list every risk associated with every activity. Some, but not all, of the risks my child may encounter
include: unpredictable or harsh weather; lightning exposure to extreme temperatures (high heat or cold); drowning; wild animals and marine
life; improper or malfunctioning equipment; slipping, falling or being struck by objects or persons; risks caused or complicated by any
mental, physical or emotional conditions any participant may have; physical contact with other participants or other individuals; and other
natural or man-made hazards. Another risk is the potential misjudgment by ROCKFISH instructors, volunteers, other staff members, co-
participants or contractors related to my child’s participation, including but not limited to decisions regarding my child’s physical condition
and capabilities, weather, water, terrain, route or medical treatment. All of these risks are inherent to the activities in ROCKFISH’s program,
which means that they cannot be changed or eliminated without altering the essential elements of the activity.
I acknowledge that participating in an ROCKFISH program involves inherent risks and other risks, hazards and dangers including
some not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma, or disability. Furthermore,
activities may take place several hours or days from any medical facility or where communication, transportation, or evacuation is subject to
delay. I understand that ROCKFISH cannot assure my child’s safety and does not seek to eliminate all of these risks of the activities of my
child’s ROCKFISH program, whether inherent to not whether described or not.
Parent/Guardian Initials: _______________ Participant Initials: _______________

9. RELEASE AND INDEMNITY AGREEMENT
I release ROCKFISH from, and agree not to pursue claim or sue ROCKFISH for, any liability, claim, suit or expense in any way associated with my
child’s enrollment or participation or the use of any equipment or facilities in the ROCKFISH program. Neither I nor anyone acting on my child’s
behalf will make a claim against ROCKFISH as a result of any loss, injury, illness, damage or death suffered by my child. This release includes any
losses caused or alleged to be caused, in whole or in part, by the negligence of ROCKFISH to the fullest extent by law and includes claims for breach
of contract or any other type of suit. I do not waive any claims for gross negligence or willful or wanton conduct.
I further agree to defend and indemnity ROCKFISH (to pay or reimburse ROCKFISH for money it is required to pay, including attorney’s
fees and costs) with respect to any and all claims brought by or on behalf of me, my child, a family member, a co-participant, or any other person for
any claims related to my child’s participation in the program or my child’s use of equipment or facilities, including claims that ROCKFISH
instructors, staff, or volunteers were negligent. However, I do not agree to indemnity ROCKFISH for claims of gross negligence or willful wanton
conduct.
ADDITIONAL PROVISIONS
I agree that the substantive law of North Carolina governs this document and any dispute or suit I have (or my child has) with ROCKFISH
regardless of the “conflict of law” rules.) Any mediation, suit, or other proceeding must be filed or entered into only in North Carolina. I agree to pay
all attorney’s fees and costs incurred by ROCKFISH in defending a claim or suit if the claim is withdraws or to the extent a court determines that
ROCKFISH is not liable for the injury or loss.
The assumption of risks, release, indemnity agreement, and all other provisions in this document are intended to be interpreted and enforces
to the fullest extent allowed by the law. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without
any effect of the enforceability of the remaining provisions, which shall continue in full force and effect. ROCKFISH has permission to use my
child’s photo or image for sale or reproduction in any manner it desires, including advertising or display. ROCKFISH reserves the right to remove
any participant from the program when staff or an instructor believes, in his/her sole discretion, the participant presents safety concern or medical
risk, is disruptive or acts in any manner detrimental to the program. If my child is dismissed or departs for any reason, I will be responsible for all
costs of early departure whether for medical reason, dismissal, personal emergencies, or otherwise.
I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT, I UNDERSTAND THAT
I AM SURRENDING CERTAIN LEGAL RIGHS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, MY MINOR
CHILDREN AND OTHER FAMILY MEMBERS, AND MY HEIRS, EXECUTORS, REPRESENTATIVES AND ESTATE.
If participant is under the age of 18 at the time this document is signed, a parent or legal guardian must sign the release in
addition to the participant’s signing.
Participant’s Printed Name: ____________________________________________________________________________________________________________
Participant’s Signature: _______________________________________________________________________________________________________________
Date: _____________________ Phone: __________________________________________ Date of Birth: ____________________________________________
Address: _____________________________________________________ City: ________________________ Sate: ___________ Zip: _____________________
TO READ AND SIGN BY PARENT/GUARDIAN OF MINOR
I hereby represent that I am the parent or guardian of the minor whose name appears above, I have read and consent/agree to the terms and conditions herein,
on behalf of said minor and myself.
X_____________________________________ _______________________________________ ________________
Guardian Signature Print Name Date

10. Rockfish Camp & Retreat Center
226 Camp Rockfish Road
Parkton, NC 28371
910-425-3529
www.camprockfish.org
Camper Behavior Contract
1. I want to be a camper at Camp Rockfish.
2. I will respect myself, my fellow campers, camp staff and camp property.
3. I will wear the proper safety gear at all times when instructed to do so.
4. I will use positive language to others.
5. I will refrain from negative physical behavior towards myself, my fellow campers, camp staff and camp
property.
6. I understand that if I do not follow this behavior contract, I may have to leave camp early.
Camper Signature: Date:
Parent/Guardian Signature: Date:
Photo & Video Release
Camper Name (print):
I grant Rockfish Camp and Retreat Center(RC&RC), its representatives and employees the right to take
photographs of my camper and their property in connection with RC&RC activities and programs. I authorize
Rockfish Camp and Retreat Center, its assigns and transferees to copyright, use and publish the same in print
and/or electronically. I agree that Rockfish Camp and Retreat Center may use such photographs of my camper
with or without his/her name and for any lawful purpose, including for example such purposes as publicity,
illustration, advertising and web content.
I have read and understand the above.
Parent/Guardian Signature: Date:
Parent/Guardian Name (print):

11. Rockfish Camp & Retreat Center
226 Camp Rockfish Road
Parkton, NC 28371
910-425-3529
www.camprockfish.org
Pick-Up Release
Camper’s Name:
□ My camper will be leaving camp during normal check-out time.
□ My camper will need to leave camp early due to an unchangeable scheduling conflict.
Along with myself, the following person(s) are authorized to pick-up ___________________ from Rockfish
Camp and Retreat Center. camper name
Name: Daytime Phone #:
Address: Cell Phone #:
Name: Daytime Phone #:
Address: Cell Phone #:
Name: Daytime Phone #:
Address: Cell Phone #:
I understand that Rockfish Camp and Retreat Center will only release my camper to the persons listed above in
addition to myself after I/they display a valid driver’s license with a name that matches what I listed above.
Name (print): Cell Phone #:
Signature: Date:

12. Rockfish Camp & Retreat Center
226 Camp Rockfish Road
Parkton, NC 28371
910-425-3529
www.camprockfish.org
info@camprockfish.org
Rockfish Camp Store Account Balance Form
Please tell your camper how much you have deposited in their camp store account and discuss with them
how they should spend it. On checkout day, the camp store will be open so that you and your child may use
any remaining balance for store purchases, or you may choose to have any balance remaining deposited into
our Campership Fund.
Please complete the following:
My camper, _____________________________________________, is aware that his/her initial store
balance is: $_____________________.
Please allow any remaining store balance to be:
____ Donated to Camp Rockfish’s Campership Fund.
____ Spent in the camp store at checkout.
Parent’s Printed Name: ____________________________________________________________________
Parent’s Signature: _________________________________________ Date: ________________________
If you have a particular concern regarding the distribution of your camp store balance, please contact our office manager.
(For office use only)
Store Balance: _______________ Donation to Campership Fund: _________________ Clerk: ________________
Rockfish Camp & Retreat Center is a ministry of the NC Methodist Camp & Retreat Ministries, Inc., which is an independent 501(c)(3) nonprofit organization,
responsible for it’s own debts and obligations. We are related by faith to the NC Conference of the United Methodist Church. Tax ID# 56-2138935

13. Stay in touch this summer with
One-Way Camper Email!
We are excited to tell you about our partnership with Bunk1.com! Bunk1’s secure, easy
to use, summer website services let you stay in touch with your camper all summer!
GET STARTED TODAY
To set up a new account and visit our Online Community:
1. Go to our website at www.camprockfish.org and click “Summer Camp” (left side)
2. Click the flashing “Camper Email” button *
3. Click “Register Now”
4. Enter your Pre-Approved Registration Code: 1210168RF
5. Fill out all the required information
6. Purchase Bunk Note credits (you will need a credit card)
7. Send an email to your camper!
* If you cannot find this button, go to www.camprockfish.bunk1.com instead and continue on to the next
step
** For your camper’s safety, please do not share the Pre-Approved Registration code above.
FREQUENTLY ASKED QUESTIONS
How do I send a Bunk Note (one-way – be with your kids! Bunk Note credits cost
email) to my camper? $1 each and are purchased in packs of
Follow the instructions above except, after various sizes.
registering, simply sign in and click on the
Bunk Notes button. Enter your camper’s Can other relatives use these services?
name, select the correct cabin, type your Certainly. Once you have set up your
message, and hit the “Send” button. account, you will be able to invite other
people to access these services.
Why do I have to pay to send Bunk Notes
(one-way email)? What do I do if I lost my username and
Each morning, the Bunk Notes system password?
bundles and sorts the messages for us to You can get it online by going to
print out and distribute to campers. It also www.Bunk1.com and clicking on the link
protects us from computer viruses and "Lost Your Password?" (to the left of the
allows us to easily manage these emails. page below the sign in button). You will
Your payment helps us cover the cost of the receive an email with your username and
system, paper, ink, and labor and, more password within a few minutes.
importantly, frees us to do what we do best
QUESTIONS OR PROBLEMS?
Please call Bunk1 at 1-800-216-9472 or go to www.bunk1.com/contact.asp