Camp Nahshii Registration & Medical Release

Camp-Nahshii-logo by Sharnay & Jeremiah, on Flickr

Hosted by This Generation Ministries (TGM)
550 Beaver Blvd, North Pole AK, 99705

@ Camp Nahshii

Camp Nahshii 2011 dates are:
Youth Camp (Grades 6-12) - July 7th -17th
(For Alaskan Native youth connected to the Yukon Flats region)

Family Camp (All ages, children must be accompanied by parent or guardian) - July 15th -17th

Please fill out this form completely so that we can provide a quality camp experience:

CAMPER INFORMATION:

* Camper Name (First & Last)

* Age:

* Grade:

* Date of Birth (Month/Day/Year):

* Name of Parent or Guardian
(First & Last):

* Mailing Address:

* City:

* State:

* Zip Code:

* Home Phone #:

* Cell Phone #:

Work Phone #:

* Church Affiliation (if any):

* Parent/Guardian E-mail address:

* Student E-mail Address:

TRAVEL INFORMATION:

TGM will be providing free transportation to and from Camp Nahshii on July 7th, returning on July 17th. The pick up and drop-off point for this free transportation is Beaver.

To arrange travel from Fort Yukon to Beaver, please note: there will be a $20 pick-up fee.

You will be contacted by the TGM staff in regards to transportation needs.
If you have any questions, feel free to contact our Yukon Flats Ministry Coordinator at 907-328-8543.

EMERGENCY CONTACT INFORMATION:
(To be used only in the event that the Parent or Guardian cannot be reached)

* Emergancy Contact Name:

* Relationship to Camper:

* Cell Phone #:

Work Phone #:

Home Phone #:

MEDICAL INSURANCE INFORMATION:

Medical Insurance Policy Name:

Policy Number or ID Number:

* Name of Clinic Used:

* Have you had an injury requiring medical attention in the past year?

Yes

* Are you currently taking any prescription or non-prescription medications?

Yes

* Have you been hospitalized
in the past year?

Yes

* Have you ever become
ill from exercising?

Yes

* Do you
have asthma?

Yes

* Do you have any conditions which
may limit participation in camp activities?

Yes

* Do you have any medical conditions
requiring treatment or medication?

Yes

* (If you have Asthma)
Do you have an inhaler?

Yes

* Do you have any
heart conditions?

Yes

* Do you have
any allergies?

Yes

If you answered "Yes" to any of the above questions, please explain below. Please also include any medical concerns or conditions not mentioned above, such as special dietary needs or restrictions:

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Note: Medical insurance is not provided by TGM

I hereby certify that this Health History and Consent Form are correct to the best of my knowledge.
I give permission for my child to attend and participate in all activities and events sponsored by TGM (This Generation Ministries). I understand the inherent risks of bodily injury involved in sport and other camp activities, but do give permission for my child to participate in them, except as noted in writing by myself or family physician. I have instructed my child to obey all of the rules of Camp Nahshii.
If I DO NOT want my child’s photo used for camp advertising or promotion, I will contact TGM in writing.

Medical/Dental Consent: I authorize TGM, in whose care my child has been entrusted, to: (1) facilitate the taking of my child’s prescribed medications; (2) administer routine medical care for minor injuries and illnesses; and (3) in my absence, consent to any emergency medical, surgical, or dental diagnosis or treatment, and hospital care to be rendered to my child on the advice of any licensed physician, dentist, or other health care provider, and I will be responsible to pay all costs incurred in connection with such medical and dental services.

Release: For myself and my spouse (if any), and on behalf of our minor child, I release, discharge, defend, and hold TGM and its staff, directors, employees, and volunteers, harmless from and against any and all claims, expenses, and any other liabilities related in any way to injuries or other losses sustained by my child as he/she attends, participates in, and travels to and from the activities and facilities of Camp Nahshii.

PHOTO PERMISSIONS:

I authorize TGM to use this camper's photographed image in promotional printing, video productions, advertizing, and any other Camp Nahshii or TGM related purposes.

* Parent/Legal Guardian Signature (Note: Your first name, middle initial, and last name typed here will be treated as a writen signature):

Camp Nahshii is free to all campers. However, there is a snack shack that requires cash for purchase. Please send your camper with spending cash so that they will be able to buy snacks.

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