Camp you wish to register for: CAmp0Fall Retreat Fall Retreat Busride*: No bus ride needed *The bus will depart from and return to the Duluth Trading Company parking lot at 8931 Old Seward Hwy., Suite A Anchorage, AK 99515. The exact times will be sent you in your confirmation email or letter. Camper: Birthday: Gender: Male Female Going into Grade: Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Adult Parent/Guardian Email: Retype Email: Phone including area code (Numbers only please): Secondary Phone: Mailing Address: City: State: Zipcode: Parental Notice and Release - Agreement is required for camper admittance I/We, the undersigned, understand that while attending Solid Rock Bible Camp of Soldotna, Alaska (camp), the below-named child may be involved in various activities including but not limited to: horseback riding, water-skiing, the waterslide, swimming, boating, the Blob, riflery, archery, rope swing, the obstacle course, and other traditional camp activities. I/We have familiarized ourselves with these programs and activities included in, but not limited to, the Camp brochure. Disagree Agree In consideration of Solid Rock Ministries, Inc. allowing the child to attend Camp for the period specified and to participate in the activities of the Camp, I/we do hereby grant permission for the child to attend and to participate fully in said activities. I/We understand and accept the risks and dangers involved in such activities and do hereby release Solid Rock Ministries, Inc., its officers and directors, its employees, agents, and the Camp staff, from any and all claims, demands, actions, causes of actions of any sort, for injuries or death sustained by myself/ourselves or the child due to negligence or any other fault during the period covered by this release, whether such an injury occurred on or off the Camp property. Disagree Agree I/We have instructed my/our son/daughter to obey the rules of Solid Rock Bible Camp. This waiver is effective only for the week(s) for which the camper is registered. Disagree Agree Health Form Emergency Contact: Home Phone Cell Phone General Health Questions Any recent injury or illness? No Yes Frequency ear infections? No Yes Any Skin Problems? No Yes Problems with sleepwalking? No Yes A Chronic or Recurring Illness? No Yes Wear glasses or contacts? No Yes An orthodontic appliance? No Yes Mono in last year? No Yes Any current medications? No Yes Frequent Headaches? No Yes Frequent stomach aches? No Yes A head injury? No Yes High blood pressure? No Yes Asthma? No Yes Emotional difficulties for which professional help was sought? No Yes Seizures? No Yes Diabetes? No Yes History of bed wetting? No Yes Immunizations current? No Yes Please explain any "Yes" answers from above Carrier Policy Number Family Physician Phone Number Family Dentist Phone Number Essential Medical Information For the safety of everyone in camp and to comply with regulations, all medication will be stored in the Health Center The following OTCM are kept in the Health Center & are provided to campers under the standing orders provided by a local physician. These would include: Acetaminophen, Ibuprofen, Robitussin DM/CF, Sudafed, Tums, Mylanta, Benadryl, and Claritin All prescriptoion medications and vitamins must be in the original container with the correct name, date physicians name, and instructions on the bottle. The camp will not administer any prescribed medications that are improperly labeled. Phone calls will be made to parents and/or physicians concering any medications about which there are any questions. SRBC food service is not providing specialized diets. Campers with dietary restrictions or needs are welcome to bring their own food. Permission to provide necessary treatment or emergency care I, hereby give permission to the medical personnel selected by SRBC to give OTCM per our standing order physician and administer treatment to my child, and if the need arises, provide transportation to a medical provider or call 911 for EMS response. I give permission for medical care by a health provider or emergency care including hospitilization, x-rays, routine tests treatment, and release of records necessary for insurance purposes. I also give permission to share health information on an as needed to camp staff. This completed form may be photocopied for trips out of camp. Parents will be notified in the case of an emergency or the need for outside medical care arises. Signature: Clear Undo Payment: Workcrew Code: Note: Your registration is not valid until the $50 non-refundable registration fee is received unless you are workcrew*. (This $50 DOES go towards the cost of the camp) You must pay $50, or pay the full amount of the camp, unless you a are registering for the waitlist then you don't have to pay a registration fee. Any remaining amount will be due the day of registration. *If you are workcrew please enter the code received in your email and after registering in the box above and your registration will be allowed. Amount to pay*: $50 $ 7979 $0 Registering for waiting list *Disregard this section if are workcrew and have put in your code. Use a credit card: Name on Credit Card: Billing Zip Credit Card # Verification Code: Expiration: Pick 01 02 03 04 05 06 07 08 09 10 11 12 / Pick 2019 2020 2021 2022 2023 2024 2025 2026 2027 OR Send a check Please make checks out to Solid Rock Bible Camp and send to 36251 Solid Rock Road #1, Soldotna, Alaska 99669, with campers name in the memo.