Registration

Camper Information and Consent Forms

PLEASE COMPLETE, SIGN, AND RETURN THESE FORMS BY June 9, 2024

A deposit of $300 is due by June 9 with the balance ($250) due by June 25.

All fields with a green * are required.

It is recommended that you submit the forms via computer or tablet. Some are having difficulties using a smart phone.

Step 1 of 3

NOTICE: While filling out these forms for Camp Areté you will be required to upload images/PDFs of your camper's medical and prescription drug insurance cards, as well as the insured party's driver's license. Please have these images/PDFs available on your computer before you begin the registration process. If you have difficulty in securing images of these items, please contact the Camp Registrar.
Camp Agape Release
Camp Areté will take place at Camp Agape in Benton, TN. Camp Agape has its own informed consent and release requirements, which must be received by Camp Agape 30 days ahead of camp. This is a separate requirement from Camp Areté’s forms, and without having this release on time, your camper will not be allowed at the camp site.

Camp Agape Participation, Media, and Medical Consent Form for Minors - 2024
I,
*
First Last
, am the parent or legal guardian of
*
Camper's first name Camper's last name
, (hereinafter “my child”), who is a
Gender of child*
Gender of child
born on
Birth date of child*
MM slash DD slash YYYY

Birth date of child
, and I am informed of the trip and activities offered by Camp Areté at Camp Agape in Benton, TN, beginning on Sunday, July 14, 2024 and ending on Saturday, July 20, 2024.

As the parent or legal guardian of my child, I understand some activities (including but not limited to eating, outdoor activities, swimming, canoeing, hiking, and team building) involve a certain degree of risk that could result in injury or death. I have carefully considered the risk involved and hereby consent for my child to attend and participate in all activities provided by Camp Agape. I hereby release and discharge Camp Agape and the Polk County Baptist Association, and their employees and volunteers from any liability, legal actions or claims which I or my child have, or might have, for any damage, injury or loss with respect to all activities associated with Camp Agape as well as their heirs, executors, administrators, successors, or assigns, from any cause of action of any nature whatsoever arising from my child’s participation in any and all activities associated with Camp Agape.

Furthermore, I agree that this agreement is deemed to be entered into in the State of Tennessee and to be governed and enforced pursuant to Tennessee law. I submit to the exclusive jurisdiction of any court of the State of Tennessee located in the County of Polk for the purpose of any dispute. I agree that in any event that I or my child take any legal action against Camp Agape or the Polk County Baptist Association, or their employees and volunteers, which is decided in favor of Camp Agape or the Polk County Baptist Association, or their employees and volunteers, I will be responsible for all legal fees, court costs and out-of-pocket expenses of Camp Agape and the Polk County Baptist Association, and their employees and volunteers.

To promote, evaluate, or otherwise describe Camp Agape’s programs and activities, I give permission to Camp Agape and its agents, to use in connection with any publication (including but not limited to brochures, booklets, videos, reports, press releases, Web sites, and exhibits) any image or recording in which my child, a minor, appears, to use and cite any comment(s), verbal or written, made by said minor about the program, and to use said minor’s name in connection with any publication and in such manner as determined by Camp Agape.

As the parent or legal guardian of my child, I hereby state that my child is in good, normal health and has no abnormal physical, emotional or mental handicaps except as listed below. I accept financial responsibility for the well-being of my child and hereby grant authority without limitation to the church/group sponsor, Camp Agape Director, employees, volunteers and agents in all medical matters to obtain medical attention, hospitalize, treat, and order injections, anesthesia, surgery in case of sickness or injury to my child. I also authorize the attending physician to provide any needed medical treatment. I also understand that it is my responsibility for advising/providing to church/group sponsor, Camp Agape Director, employees, volunteers and agents information/instructions for all pre-existing medical conditions and/or physical, emotional, or mental handicaps.

I, the undersigned, have read, understand and accept all of the terms and conditions set forth in this agreement. I do hereby verify that the information provided is correct, and I do hereby release and forever discharge all sponsors, Camp Agape and Polk County Baptist Association from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage or injury or death or loss of property while participating in Camp Agape. Also, I understand that a copy of this form is as valid as the original. In the event of an accident, injury, or illness while my child is participating with Camp Agape their personal insurance or church’s insurance is the primary insurance carrier. Camp Agape’s liability insurance is secondary.
Parent/Guardian signature*
Date*
MM slash DD slash YYYY

Camper Information
Age*
T-shirt size*
Name(s) of custodial parent(s)*
First Last
Custodial parent's email address*
Enter Email Confirm Email
Home phone*
Father's cell
Mother's cell
Father's work phone
Mother's work phone
Father's email
Enter Email Confirm Email
Mother's email
Enter Email Confirm Email
Preferred parent contact phone number*
Camper's cell
Camper's email
Enter Email Confirm Email
Home address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency contact information
In the event that parents cannot be reached, whom should we call in an emergency?
Emergency contact if parent not available*
First Last
Relationship to camper*
Phone*
Please indicate*
Family physician name*
First Last
Family physician phone number*
Medical insurance information
Note: If you do NOT have health insurance coverage, please indicate N/A in the required spaces. Where phone numbers or plan numbers are requested, please fill in with zeros, as in (000) 000-0000.
Name of policy holder*
Full name
Policy holder's date of birth*
MM slash DD slash YYYY
Name of insurance carrier*
Carrier phone number*
Group number*
Policy number*
Billing Address*

Complete insurance carrier billing address
Prescription plan provider*
Prescription plan number*
Prescription plan phone number*
List food allergies
List insect allergies
Require Epipen?*
Other allergies, current medications, and/or medical conditions
Please scan or take a picture of the FRONT and BACK of the insurance and prescription drug cards.

Also, please include scans or photos of the FRONT and BACK of the driver’s license of the person who holds the insurance. Usually insurance is through the parent’s place of employment. In that case, the driver’s license of the parent is needed. Use the Select files buttons below to upload those images or PDFs with this form.
Upload files for insurance cards (front & back) and prescription plan cards (front & back)
Drop files here or

Accepted file types: jpg, png, pdf, tif, jpeg, Max. file size: 512 MB.
Upload files for insured's driver's license (front & back)*
Drop files here or

Accepted file types: jpg, png, pdf, tif, jpeg, Max. file size: 512 MB.

Informed Consent
Please read the following statements carefully so that you are fully aware of the consent you are giving to Camp Areté and sign in the signature box below.
- Consent to attend: The health history is correct and complete to the best of my knowledge. The person herein named has permission to engage in all camp activities except as noted. I understand that part of the camp experience involves activities and group living arrangements and interactions that may be new to my child, and that they come with certain risks and uncertainties beyond what my child may be used to dealing with at home. I am aware of these risks, and I am assuming them on behalf of my child. I realize that no environment is risk-free, and so I have instructed my child on the importance of abiding by Camp Areté’s rules. My child and I both agree that he/she is familiar with these rules and will obey them.
- Meal consents: I understand that it is my child’s responsibility to manage his/her own food avoidances with available menu choices. Camp Areté is unable to store special ingredients or prepare special meals. Camp Areté is entirely incapable of accommodating allergies to corn or soy. Exceptions will be made at the discretion of the kitchen director in consideration for camp staff and other campers.
- Consent to Treat a Minor: I hereby give permission to the camp to provide, seek, and consent to routine health care, administer prescribed medications, administer over-the-counter-medications as necessary, and emergency treatment for me/my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to arrange related transportation. The attending provider, appropriate staff, and Camp Areté, its officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical and or surgical treatment and are hereby released from any and all claims and causes of caution that may arise, grow out of or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability.
- Consent to release medical information to camp staff: It is my intention that the camp be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of the camp be treated as personal representatives for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR 164.510(b)) to the disclosure to camp representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to the camp representatives related to the person’s ability to participate in camp activities; and (ii) in the case of minors to provide relevant information to the camp representatives to keep me informed of my child’s health status. This authorizes all associated medical staff, including EMTs, nurses, physician’s assistants, and medical doctors to release information concerning the medical status, medical condition, injuries, prognosis, and diagnosis and related personally identifiable health information of my child to camp staff. This information includes injuries or illnesses relevant to participation in the above-named camp.
  The reason for this disclosure is to advise camp staff of the nature, diagnosis, prognosis or treatment concerning any medical condition and any injuries or illnesses the camp participant may have so that good decisions can be made regarding the participant’s ability and suitability to participate in camp activities. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations.
  I understand that I may revoke this authorization in writing at any time by notifying Camp Areté, but if I do, it will not have any effect on actions Camp Areté took in reliance on this authorization prior to receiving the revocation. This consent expires one year from the date it is signed.
  In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Camp Areté to secure and administer treatment, including hospitalization, for my child. This completed form may be photocopied for trips out of camp.
- Consent to release medical records: I agree to release any records necessary for referral billing or insurance purposes.
- Consent to Render Payment: Should medical care beyond the capabilities of camp staff be required for my child, I agree to assume responsibility for the payment of these services.
- Travel: I have read the travel information and understand that Camp Areté assumes no responsibility for transportation to or from Tennessee and that other transportation options mentioned are merely coordination efforts on behalf of volunteers.
- Hold harmless: The undersigned does hereby give permission for my child or me to attend and participate in all activities sponsored by Camp Areté and hereby agree to hold harmless the camp, its staff and program leaders, and associated churches in the event of injury or accident. The undersigned does also hereby give permission for my child or me to ride in any vehicle designated by the adult in whose care the minor has been entrusted while participating in or traveling to/from events.
- Media release: If you prefer that your child’s name or picture not appear on the blog, website, or in promotional materials, please indicate by marking the “opt out” box below. Note that Camp Areté is unable to remove images from any video, regardless of the opt-out option.
- Camper opts out of his/her name and/or photo on the Camp Areté website or blog.
Video disclaimer*
- Notice: If your camper appears in a video taken during camp, we are not able to edit out your camper from the video.
Parent signature*
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Exciting Opportunity for 2024!

Camper Information and Consent Forms

Step 1 of 3

Camp Agape Release

Camper Information

Emergency contact information

Medical insurance information

Informed Consent

About Camp Areté

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