2013 Minnesota Boys Statewide Camp Out MAY 17-19 Lake Placid ...

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Sponsored by: Minnesota District Royal Rangers 1315 Portland Ave S Minneapolis MN 55404 Phone: (612) 332‐2409 2013 Boys’ Statewide Campout Lake Placid Bible Camp – Pillager, MN May 16‐19, 2013 Church Registration Cover Sheet Church _________________________________________ Date _____________________________________________ Address ________________________________________ Church Leader _____________________________________ City ___________________________________________ Chartered Yes No State ___________ Zip ________________________ Outpost Number (if applicable) _______________________ 1. We plan to bring the following number to this year’s Statewide Campout: _____ Grades 3‐5 _____ Grades 6‐8 _____ Grades 9‐12 _____ Leaders/Adults Total number of people _____ 2. T‐shirts are included in the registration fee. Give total number of each size T‐shirt size for your Outpost: YS L YM XL YL 2XL Early Registration postmarked by April 19 th , 2013: Chartered Outposts & First Time Churches: _____ People x $50.00 = $ ________ Total due: $ ________ Minimum $15 per camper: = $ ________ Amount enclosed : $ ________ S 3XL M 4XL Total number of shirts _____ Non‐Chartered Churches: _____ People x $65.00 = $ _______ Total due : $ _______ Minimum $15 per camper: = $ _______ Amount enclosed : $ _______ Pre‐Registration postmarked between April 20 st & May 10 th , 2013: Chartered Outposts & First Time Churches: _____ People x $65.00 = $ ________ Total due: $ ________ Minimum $15 per camper: = $ ________ Amount enclosed : $ ________ Upon Arrival: Chartered Outposts & First Time Churches: _____ People x $70.00 = $ ________ Total due: $ ________ Minimum $15 per camper: = $ ________ Amount enclosed : $ ________ Non‐Chartered Churches: _____ People x $80.00 = $ _______ Total due : $ _______ Minimum $15 per camper: = $ _______ Amount enclosed : $ _______ Non‐Chartered Churches: _____ People x $85.00 = $ _______ Total due : $ _______ Minimum $15 per camper: = $ _______ Amount enclosed : $ _______ Please fill out and mail deposit payment together. FOR OFFICIAL USE ONLY Date: ___________ Check No: ____________ Amount: ___________ Mail forms and registration fee to: MN District SWC Coordinator 9435 Polaris Ln N Maple Grove MN 55369 Attn: Julie Hickle
Minnesota District Assembly of God 1315 Portland Ave S Minneapolis, MN 55404 (612) 332‐2400 Ranger Parent(s): Please completely fill out and sign this form. For your son’s protection and safety, he will not be able to participate in any Royal Ranger District event without it. Minnesota District Royal Ranger 2013 PERMISSION / EMERGENCY MEDICAL AUTHORIZATION For all boys and youth (Kindergarten to 12 th grade) This medical emergency form MUST be signed by a parent or guardian, and accompany the minor who wishes to participate in the Minnesota District Royal Ranger event. Child’s Name: Date of Birth: Street Address: Home phone: ( ) City / State / Zip: Social Security #: Father’s Name: Work / Cell phone: ( ) Mother’s Name: Work / Cell phone: ( ) Family Doctor: Office phone: ( ) Insurance Company: Policy Number: MEDICAL QUESTIONNAIRE Please answer ALL of the following questions. EXPLAIN any “YES” answers completely in the space provided below. Does your son have or is currently being treated for: Yes No 1. Any injury/ illness or taking any form of Yes No 12. Has your son ever had any operations? medication? Yes No 2. Asthma? Yes No 13. Is there any family history of any disease? Yes No 3. Allergies to any medication? Yes No 14. Has your son had any “Childhood Diseases” (i.e. Yes No 4. Hay fever? measles, mumps, chicken pox, etc)? Yes No 5. Other known allergies? Yes No 15. Does your son ever sleepwalk? Yes No 6. His tonsils removed? Tylenol Yes No 7. His appendix removed? What may we give your son for pain or fever? Aspirin Yes No 8. Require a special diet? Ibuprofen Yes No 9. Any chronic medical problems (i.e. cardiac, respiratory, kidney, seizure or other problems)? Yes No 10. Color blindness? Yes No 11. ADD or ADHD? (Is he on medication?) How would you classify your son’s swimming ability? In addition to the above explanations, list any other medical considerations not mentioned above? What is the date of your son’s last physical? What is the date of your son’s last tetanus shot? Beginner Intermediate Advanced Person(s) to contact in the event of an emergency: Name: Phone: ( ) Name: Phone: ( ) “I have read and approved the included information. You have my permission for my child to attend the camp and to participate in its activities. I, acting on my own behalf, also release the Minnesota District Royal Rangers and/or Lake Placid Bible Camp, its agents, assigns, staff, employees as well as volunteer workers from any liability whatsoever arising out of property damage or loss as well as any injury, sickness or death which may be sustained by my child as the result of any participation in any camp activity. I am aware of the risks associated with participating in camping activities and accept participant’s participation with full awareness of these risks. “I give my permission for the camp medical personnel to treat the listed participant in the event of a minor illness or minor injury. In case of emergency, and when I am unable to be contacted, I hereby give permission to the local physician selected by the camp to hospitalize, secure proper treatment for, order injection, anesthesia, or surgery for my child. I authorize the MN District Royal Rangers to use our child’s likeness in photographs or video in any and all of its publications and in any and all other media. I will make no monetary or other claims against the District for the use of such photos or videos. I authorize camp personnel to inspect camper’s belongings to see that they have not brought any prohibited or illegal items. I understand that if my child misbehaves and violates the camp rules, I may be called to pick him/her up.” Signature of parent or legal guardian Date Print name
Page 1 and 2: 2013 Minnesota Boys Statewide Camp
Page 3 and 4: GENERAL INFORMATION “Switch” wi
Page 5 and 6: THINGS TO BRING Bible Notebook Pen/
Page 7 and 8: STATEWIDE CAMPOUT RULES NKCC is of
Page 9 and 10: 1 2013 STATEWIDE CAMPOUT SKILL-A-RA
Page 11 and 12: RANGER DERBY RACING Excitement, cha
Page 13 and 14: REGISTRATION FEES Early registratio
Page 15: REGISTRATION PROCESS Please read im
Page 19 and 20: Church: Address: Church Final Regis
Page 21 and 22: STATEWIDE CAMPOUT EXAMPLE MENU (Men
Page 23 and 24: STATEWIDE CAMPOUT DUTY ROSTER Patro
Page 25 and 26: STATEWIDE CAMPOUT INSPECTION SHEET
Page 27 and 28: STATEWIDE CAMPOUT EVENT LISTING SIG
Page 29 and 30: Minnesota Royal Rangers Toolcraft S

2013 Minnesota Boys Statewide Camp Out MAY 17-19 Lake Placid ...

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