Participant Information

* First Name

* Last Name

* Birth Date

* Age

* Male/Female

* Program or Event Name (e.g., Your Church Group or School's Name)

* Participant is a:

Participant's Parent or Emergency Contact Information

* Participant's Primary Address

Address 2

* City

* State

* Zip

PRIMARY CONTACT INFORMATION

* Primary Contact's Full Name

* Primary Contact's Relationship to Participant

* Phone Number to Call First

* Phone Number to Call Second

Primary Emergency Email Address

SECONDARY CONTACT INFORMATION

Secondary Contact's Full Name

Secondary Contact's Relationship to Participant

Phone Number to Call Third

Phone Number to Call Fourth

Secondary Emergency Email Address

Can we email or mail you information about our camp programs?

Yes

No

Acknowledgement of Risk and Acceptance of Responsibility

*

By checking the box below, I certify that I am adult, or a parent/guardian of a minor participant, and I/we recognize that there is a significant element of risk in any adventure sport or activity associated with the outdoors. Knowing the inherent risks, dangers and rigors involved in the activities, I certify that the participant is fully capable of participating in the activities.

I/we assume full responsibility for myself and my family, bodily injury, death, loss of personal property and expenses thereof, as a result of my negligence or the negligence of my family.

I/we further understand that Red Oak Camp reserves the right to refuse participation to any group or individual it judges to be incapable of meeting the rigors and requirements of participating in any or all the activities.

I/we agree to respect and uphold all “Red Oak Camp Regulations and Procedures” and failure to do so can result in program termination without a refund.

Yes, I agree with the above statement

Permission to Treat in the Event of An Emergency

*

By checking the box below, I certify that I am adult, or a parent/guardian of a minor participant, I am certifying that the information about the participant correct and accurate. I give permission to the physician or health professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the participant for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the camp 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.

From the ACA Health History Form.

Yes, I agree with the above statement

The participant has medical insurance?

View Red Oak's Statement of Activities

Please review Red Oak's Statement of Activities. After reviewing our reviewing our activities, please select one of the following:

Select one of the following to confirm you have reviewed Red Oak's Statement of Activities:

Please describe any current physical, mental, or psychological conditions that require restrictions on activities at camp, or special considerations in working with your camper.

Allergies and Special Dietary Conditions

Please tell us if the participant has any allergies:

Give us more information about the participant's allergies here, or tell us about an allergy not listed above. Also list dietary restrictions:

Please Print this Page and Deliver it to Red Oak

* Indicates Response Required

	Yes	No
Food Allergies
Medical Allergies
Bees or other stinging insects
Hay Fever or Airborne Allergens