Parental Consent, Certification and Medical Authorization

Parents and legal guardians of minor children are asked to completes this form and return it to A Place in the Heart. The information requested is designed to assist in providing for the safety of minors during activities regarding A Place in the Heart.

General Information (please print)

Child’s Name _______________________________Date of Birth__________________

Father’s Name________________________ Mothers Name_______________________

Child’s Address__________________________________________________________

Home Phone#___________________Daytime Phone#___________________________

Personal Physicians Name___________________________Phone__________________

In emergency Notify________________________________Phone_________________

Insurance Company Covering Child__________________________________________

Policy Number____________________________________Phone__________________

City ___________________________State______________ zip___________________

………………………………………………………………………………………

Medical Questionnaire

Past Illness:

___Frequent Colds ___Kidney Problems ___Heart

___Sleep Walking ___Sinusitis ___Diabetes

___Ear Problems ___Fainting ___Asthma

___Stomach Upsets ___Menstrual Problems ___Other

Other diseases or details of above_______________________________________

Immunizations and other information (this must be completed)

Date of last tetanus (or DPT) shot__________

Doctor or clinic_____________________________________________________

Any Medical Treatment the camper is currently receiving____________________

Any medication the camper takes on a regular basis_________________________

Medical conditions (treated or not, current or on going) about which the camp staff should be informed__________________________________________________

__________________________________________________________________

If health history shows physical limitations or restrictions for vigorous camp activates, your camper is required to have a doctor’s permission for activities or an indication of limitations. (Attach to this form)

Do you have any allergies? ___Yes ___No

· Bee Stings_______ is the reaction severe? ___Yes ___No

· Foods___________ is the reaction severe? ___Yes ___No

· Drugs___________ is the reaction severe? ___Yes ___No

· Aspirin__________ is the reaction severe? ___Yes ___No

· Other___________ is the reaction severe? ___Yes ___No

…………………………………………………………………………………………..

Medical Treatment Authorization

I understand that I will be notified in the case of medical emergency involving my child. However, in the event that I cannot be reached, I authorized the calling of a doctor and the providing of necessary medical services in the event that my child is injured or becomes ill. I understand that A Place for the Heart will not be responsible for medical expenses incurred solely on the basis of this authorization.

I agree to notify A Place for the Heart in the event of any health changes, which would restrict my child’s participation in any normal activity. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within physical capabilities of my child.

A facsimile or photocopy of this form shall be as valid as the original.

__________________________ _________________________________

Signature of Parent or Guardian Date

Note: if you are a legal adult living on your own please sign below.

__________________________ _________________________________

Signature of Camper Date

Please check which camp you will be attending:

June 21-26______ July 12-17_______

Please check form of payment:

check______ Credit______-______-______-______exp._____/_____

paying on arrival____________

Please mail this form back to: Creative Worship Camp A Place in the Heart

4214 Beckerdite Rd. Sophia, NC 27350

Dear Parent / Camper,

Hello and welcome to Creative Worship Camps 2006. We have been eagerly expecting this summer and all God has in store for the camps. The camps will not only be a time of worship but also a time of exploring the heart of the Lord through the arts. The past four summers have been some of the most anointed times with the Lord that we have ever experienced. We pray that the Lord has been stirring your heart for the week that you will be spending with us.

Registration will begin at 4:00pm on the Tuesday you arrive, and end at 3:00pm on the Sunday of the camp you will be attending. This will be a small camp with only 20 campers, so there will be a lot of one on one time and the meetings will be very intimate and involved. All campers must be from 14-18 years old. We hope that each camper is prepared to be stretched and experience a new dimension of worship during the camp, also come to have a lot of fun. Please remember here at A Place in the Heart we don’t believe in “camp food”, so bring a hungry stomach for some amazing food, and amazing atmosphere.

All campers will be staying in separate guy-girl cabins, a mattress and pillow is provided along with showers. The following is a list of things each camper will need:

Sleeping bag or blanket

Pillowcase

Flashlight

Bathing Suit (one piece for girls)

Jacket or sweatshirt

Tennis Shoes

Old paint clothes (clothes you can get dirty)

Any personal art supplies or instruments you would like to use

Bug spray

Towels

Toiletries

If you have questions please call 336-861-1407 or email at aplaceforheart@msn.com -A Place in the Heart Staff