Trinitypines.org

Registration Form (All Campers and Sponsors) INSTRUCTIONS: Complete the Registration form in its entirety for each person attending. All requested information is applicable. Type or print legibly
in dark ink.
Name: ______________________________________________________________________ First Middle Last (indicate name used) Mailing Address: __________________________________________________________________________________________________________ Street City State Zip Sex: (M/F) _____ Home Phone: (______)___________________ Name of Church or Group with whom you are attending: __________________________________City: _________________________ State: ____ Parent / Legal Guardian: __________________________________________________ Relationship to You: ____________________________ Parent / Legal Guardian Phone Number: Daytime (______)_____________ Evening (______)_____________ Other (______)_______________ Parent/Guardian Email:______________________________________________ I, and my parents or legal guardian (if a minor), am/are fully informed about and aware that during my stay at Trinity Pines Conference Center, Trinity, TX, also known as Trinity Pines, certain risks and dangers will occur. These include, but are not limited to, the hazards that arise from being in a wilderness area, the forces of nature and other hazards arising out of the content of this program which include, but are not limited to, volleyball, soccer, softball, basketball, archery, wilderness hiking, swimming, use of watercrafts, and a challenge course which has a climbing wall, zip lines, high and low elements, and a team power pole. In consideration of Trinity Pines providing and my willingness to engage in these rigorous activities and a special environment, I have and do hereby hold Trinity Pines its owners, officers, directors, trustees, agents, employees, and/or volunteers, harmless from any and all claims, liabilities, suits, actions, causes, damages or losses and demands of every kind and nature whatsoever, including without limitation, all costs and attorney’s fees, which may arise from or in connection with my stay or participation in any activities arranged for me by my organization or my group leaders or Trinity Pines. Injuries may include, but are not limited to, emotional injuries, physical injuries, or death. The terms hereby shall serve as a release and assumption of risk for me, my heirs, executors, administrators, and for all members of my family. I authorize the use of my or my child’s photograph or video on the Trinity Pines website or brochures for camp updates and communication. In case of an accident or illness, I authorize first aid/medical personnel to examine, treat, or administer medications for any illness or injury to myself or my
child as deemed necessary. In the event of an emergency involving my child and if I cannot be reached by telephone, I authorize such persons to obtain
any medical care (including hospitalization, injection, anesthesia, and surgery) from a licensed, certified, or authorized health care provider for my child as
deemed necessary. I accept sole responsibility for the payment of any medical care for me or my child. I hereby release, indemnify and hold harmless
Trinity Pines, its owners, officers, directors, trustees, agents, employees, and/or volunteers, from and against any and all claims, liabilities, or damages
arising from any act, omission, negligence, or gross negligence of any such health care provider or of Trinity Pines, its agents, and employees.
I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Texas
and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release
contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.
I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE
AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and have understood.
X____________________________________ __ __________ X_____________________________________ _ ___________
Signature Date
Parent or Legal Guardian Signature (if minor) Date
MEDICAL RELEASE FORM (All Campers and Sponsors) In the event of an accident or special health needs, it will be necessary for us to have the requested information. Please make certain that you have provided thorough and accurate medical information. It is recommended that you attach a photocopy of your family medical insurance card. Name: _________________________________________________ Birth Date: _____/_____/_____ Age: ___ Sex: (M/F) _____ First Middle Last Mo. Day Year Church: ________________________________________________ City: _____________ Dates at TPCC: _____/____/____ to _____/____/____
Person to Notify in Event of Emergency: ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________ If unable to reach above person: Notify ______________________________________________ Relationship to You: __________________
Phone Number of Contact Person: Daytime (______)_______________ Evening (______)________________ Other (_______)__________ Family Physician: _________________________________________________ Phone: (_______) ______________________________ Medical Insurance Co.: ____________________________________________ Plan or Group #: ________________________________ Insured ID or Member #: ___________________________________________ Ins. Co. Phone #: (_______)_______________________ MEDICAL INFORMATION
Diseases, Chronic or Recurring Illness: (Check all that apply, explain)  Asthma: _____________________________________________  Food: _______________________________________________  Bleeding Disorder: ____________________________________  Insect Sting: __________________________________________  Joint or Back Problems: _____ _________________________  Medicine/Drug: _______________________________________  Diabetes: ____________________________________________  Plant/Pollen: __________________________________________  Epilepsy: _________ ________________________________  Other: _______________________________________________  Heart Condition: _______________________________________ Special Diet: ____________________________________________  Seizures: _____________________________________________ Recent Surgery? _________________________________________  Stomach Condition: _____________________________________ Date of last Tetanus Shot? ______ Immunizations Current? ______  Emotional: ____________________________________________ HEALTH CARE AND CAMP PERMISSION— INITIAL & SIGN THE STATEMENTS BELOW.
___ I give permission for first aid techniques and simple health care to be administered as the need arises. I understand in the event of any serious
injury or illness on my part the camp officials reserve the right to seek professional medical attention including but not limited to consultation with medical
director, EMS transportation, and hospitalization.
___ I give permission for myself or my child/ward, in consultation with the Camp Health Supervisor and/or the medical director’s standing orders, to take
the following medications as indicated by checking below:
___antihistamine (i.e. Benadryl, Claritin) I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that I or my child/ward am/is in acceptable heath, physical ability, and emotionally ready to fully participate in camp or retreat activities. I grant my permission to participate in all activities associated with the enrolled event with the exceptions of those that are noted. I, _______________________________ being the legal guardian of ______________________________________(if applicable)give my permission to Trinity Pines Conference Center’s management, medical staff, and/or the group director to provide medical treatment that may be deemed necessary to insure the well-being of myself/the named camper. I do hereby release and forever discharge all from any and all claims, demands, actions or cause of action arising out of damage or injury while participating in Trinity Pines sponsored activities. X ___________________________________________________ ____/____/____ (_______) ____________________________
Signature Date Phone Number
MEDICATION ADMINISTRATION AUTHORIZATION (Accompanies Medications) Name: _____________________________________________________ Birth date: _____/_____/_____ Age: ___ Sex: ___ Male ___ Female Church Name: _________________________________________ Church City & State: ___________________________________________ As the parent or legal guardian of the above-named child, I give my permission to the Trinity Pines Medical Staff to administer as prescribed by law the listed below medication to my child. X_______________________________________________ _________ (______) ____________________ (______) ___________________
Parents/Guardian Signature Date Daytime Phone # Evening Phone #
OR
As an Adult Camper/ Sponsor/Staff, I give my permission to the Trinity Pines Medical Staff to administer as prescribed by law the listed below
medication to me during my stay at Trinity Pines Conference Center.
X_________________________________________ _________
Adult Camper / Sponsor/Staff Date

For Prescription Medications only.PLEASE follow these guidelines: In accordance with Texas Department of Health regulations: ALL
Medication that is brought to camp must be: (1) Placed in a secure location not accessible to campers, (2) Prescribed for the camper (not a
sibling or parent), (3) In the original container with all labels intact, and (4) Correct current dosage.
Dosage of non-prescription medication may not exceed product recommendation without doctor’s written orders. TPCC staff request that you do not
send over-the-counter medications (i.e. Tylenol, Ibuprofen, Benadryl, etc). These types of medications are provided by TPCC).
Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________ Name of Medication: ____________________________________________________________________________________________________
Purpose for medication use (e.g. allergies, asthma, antibiotic) _____________________________________________________________________ Form of medication: ___ Tablet ___ Pill ___ Capsule ___Liquid ___ Inhalation ___ Other (specify) ___________________________________ Dosage (amount to be given): _________________________________ How often or at what time: ______________________________________ Remarks or special instructions: ____________________________________________________________________________________________
If necessary, make additional copies of this blank Medication Form in order to provide requested information for each medication. All Medication
Release/Administration Forms and medication(s) to be administered should be given to the church Contact Person prior to arriving at TPCC. When
the church group arrives at camp, the Contact Person will be responsible for bringing all medications and forms to the TPCC Office. The Forms will be
reviewed by our Medical Staff to clear up any possible questions about medications or their administration. To make it easier for the church Contact
Person, the parent/or student should put their medications and signed Medication Administration Authorization forms in a zip-lock type
plastic bag with the student’s name and church written with a marker on the outside of the bag. Parents should emphasize to their child(ren)
the responsibility of reporting to the camp Health Center for their medications while at camp.

Source: http://www.trinitypines.org/uploadedFiles/3/Individual%20Camper%20Packet.pdf