Art Camp Registration

2024 Youth Art Camp Registration

Use this form to register for the youth art camp at Park of the Pines sponsored by the Michigan Mission Center.

Step 1 of 5

Parent/Guardian Information
Name*
First Last
Address*
Same as Camper's Address

Street Address City State / Province / Region ZIP / Postal Code Country
Primary Phone Number*
Work/Emergency Phone Number
Email
Hidden
Parent/Guardian Sign Out
Hidden
Sign Out
Hidden
Medication Sign Out

Releases
Photo Release (Optional)*
- I will consent to a photo release for my child.
- I do not consent to a photo release. Images of my child may not be released or distributed.
Photo Release – I hereby give consent to and authorize the taking of photographs or videotape in which my child, the camper named above, may appear and circulate same for any and all official resource, use or purpose including print, film or electronic reproduction of every description. I hereby waive all right of privacy in and to any said pictures or tapes by signing my name below.*
Michigan Medical Emergency Care Authorization – Notice: by signing your name below you are granting the operator of the camp organization authority to secure emergency medical, surgical treatment for your camper while attending camp if there is insufficient time to contact you. You are giving the camp operator permission to secure routine, nonsurgical medical care for your child while attending camp. In accordance with MCLA Act 116 of the Public Acts of 1973 and the rules for licensing children's camp, this authorization must be signed by a parent or guardian unless there is a religious objection. MCLA 722.124a, Section 14a(2) states: "A parent or guardian of a minor child who voluntarily places the child in a child care organization shall execute a written instrument investing the organization with authority to consent to emergency medical and surgical treatment of the child. The parent of guardian shall consent to routine, nonsurgical medical care.*
Consent to Medical Treatment & Transportation: As the Registrant, or if under the age of 18 (19 in Alabama, Alaska, Wyoming and Nebraska, 21 in Pennsylvania, Puerto Rico, Mississippi and Colorado), the parent or legal guardian of the Registrant listed on this form, I give permission to Community of Christ to transport the Registrant to a physician or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and I will assume the responsibility for payment of all expenses and bills resulting from medical treatment. Community of Christ personnel may administer prescription medication as needed during the Event, and I agree that if the Registrant has an illness on the day the Event begins that could be harmful to him/her/them or to others, he/she/they will not be allowed to begin the Event. I consent to Community of Christ personnel administering a COVID-19 test if the Registrant demonstrates symptoms of COVID-19 and I agree that he/she/they will be isolated and required to leave camp if testing is positive for COVID-19 or other communicable disease.
Waiver & Release of Liability – Waiver and Release of Liability In consideration for acceptance for my participation in the Event, or as parent/guardian of the Registrant, I do for myself and on behalf of the Registrant, if said Registrant is not 18 years of age or older (19 in Alabama, Alaska, Wyoming and Nebraska, 21 in Pennsylvania, Puerto Rico, Mississippi and Colorado), hereby release, forever discharge and agree to hold harmless Community of Christ and its affiliated organizations, lessors, lessees, officers, representatives, subordinate units, contractors, campgrounds, Event directors, staff, priesthood, agents, volunteers, participants, and employees thereof from any and all damages (including consequential damages), liability, claims, judgments, penalties, obligations, fines, causes of action, demands, losses, costs, and expenses (including without limitation reasonable attorneys’ fees and court costs) for personal injury, sickness or death based upon ordinary negligence, as well as property damage and expenses of any nature whatsoever which may be incurred by the parent/guardian and the Registrant occurring while Registrant is participating in the Event or arising thereafter, and further agree to hold harmless and indemnify said organizations and their lessors, lessees, officers, representatives, subordinate units, contractors, campgrounds, Event directors, staff, priesthood, agents, volunteers, participants, and employees for any liability sustained by them as the result of the negligent, willful or intentional acts of said Registrant during the Event, including expenses incurred attendant thereto.
Adults Authorized to Release Camper
A camper may only be released to an adult who is authorized by the parent/guardian. Please list any additional adults who are authorized to sign for release of the camper either due to emergency or at the end of camp.
Authorized Adult #1 Name
Authorized Adult #1 – Phone Number
Relationship of Adult #1 to Camper:
Authorized Adult #2 Name
Authorized Adult #2 – Phone Number
Relationship of Adult #2 to Camper:
Authorized Adult #3 Name
Authorized Adult #3 – Phone Number
Relationship of Adult #3 to Camper:

Camper's Health History & Medical Information
Health Insurance Provider*
Health Insurance Policy Number*
Health Insurance Group Number
Name of Person Insured*
Please upload a picture of the insurance card.
If you are not able to upload a picture at this time, then a photo copy will need to be made or provided during on-site registration.
Max. file size: 2 GB.
Name of Camper's Doctor
Phone Number of Camper's Doctor
Emergency Contact Person*
Please provide contact information for an adult different from the parent/guardian completing this registration who may be contacted in the event of an emergency.
First Name Last Name
Emergency Contact Phone Number*
Relationship of Emergency Contact to Camper*
Please describe any food allergies, dietary restrictions, or other eating habits:*
Please describe any behavioral or emotional needs (IEP, 504, behavior plans, ADHD/ADD, autism spectrum, sensory issues, eating disorders, PTSD, or recent/lasting traumas):*
Please describe any ongoing health conditions or infectious diseases (bed wetting, sleeping disorders, physical limitations, skin conditions, asthma, hearing or vision impairments, diabetes, or others):*
Please describe any other camper needs:
Please list the medication, dosage, frequency, and condition treated for each medication being sent to camp:*
All medications sent to camp need to be in the original container with instructions.
Please list any medication allergies:
Immunization Record
Please upload a picture of your child’s immunization record. If you are not able to upload the record, then a photo copy will need to be made or provided during on site registration.
Max. file size: 2 GB.

2024 Youth Art Camp Registration

Step 1 of 5

Camper's Information

Parent/Guardian Information

Releases

Adults Authorized to Release Camper

Camper's Health History & Medical Information

Donations to Support Summer Youth Camps