Registration Request Form--

Please complete the following form for Step 1 of the Registration Request Process.  All fields marked with an (*) are required.  Once the form is completed, press the "Submit" button at the bottom of the page.  If this form is not completed in full and not submitted, no information will be saved.  Thank you.
 

School Name	*
6th Grade Camp Week	*
GENERAL INFORMATION
Camper's First Name	*
Camper's Last Name	*
Gender	*	Female Male
Birthdate	*	- - Choose One - - January February March April May June July August September October November December *- - Choose One - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * 1997 1998 1999 2000 2001 2002
Age	*
Grade	*	5th 6th 7th
Address	*
City	*
State	*	- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip	*
Camper's Home Phone Number	*
Parent/Guardian E-mail	*
Confirm Parent/Guardian E-mail	*
Is this the FIRST TIME camper will be attending camp at IHC?	*	Yes No
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name (1) (First & Last)	*
Relationship (1)	*	Father Mother Grandparent Legal Guardian Other - Please describe below.
If other, please define (1):
Parent/Guardian Home Phone Number (1)	*
Parent/Guardian Cell Phone Number (1)
Parent/Guardian Work Phone Number (1)
Parent/Guardian Name (2) (First & Last)
Relationship (2)		Father Mother Grandparent Legal Guardian Other - Please describe below.
If other, please define (2):
Parent/Guardian Home Phone Number (2)
Parent/Guardian Cell Phone Number (2)
Parent/Guardian Work Phone Number (2)
FOR OTHER THAN PARENT/GUARDIAN, the following is an authorization for persons named below to pick up my child for transportation purposes. I hereby authorize Indian Hills Camp to release the above named camper to a Parent/Guardian, Group Leader/School Teacher, or to one of the following individuals:
Pick-Up Authorization 1.	*
Pick-Up Authorization 2.	*
Pick-Up Authorization 3.
For the protection of my child, the following individuals are not allowed to have my camper released to him/her or to visit my child at IHC.
Not Permitted to Pick-Up 1.
Not Permitted to Pick-Up 2.
HEALTH HISTORY INFORMATION
Medical Insurance
Family Health Insurance Carrier	*
Policy #	*
Doctor
Doctor's Phone Number
Immunization Information
IMPORTANT: The State of California requires that every camper submit the following immunization information (mm/yyyy). If your child is not immunized, please choose "My Child is Not Immunized":
DTaP (tetanus):	*	January February March April May June July August September October November December My Child is Not Immunized* 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 My Child is Not Immunized
MMR:	*	January February March April May June July August September October November December My Child is Not Immunized* 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 My Child is Not Immunized
Hep B:	*	January February March April May June July August September October November December My Child is Not Immunized* 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 My Child is Not Immunized
Varicella:	*	January February March April May June July August September October November December My Child is Not Immunized* 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 My Child is Not Immunized
Additional Immunization Information:		Had Chicken Pox Disease (please indicate month and year in Varicella boxes)
Current Health Conditions
Please mark all that apply.		Heart Condition ADHD Homesickness Diabetes Asthma Epilepsy Bed Wetting
Current Medications
Current Illness/Injury
Food Allergies
Medication Allergies
Environmental Allergies
Diet Restrictions
Activity Restrictions
Other Health History Information
Please check "Yes" or "No" next to each type of medicine below to indicate your permission to be administered, as needed, by the Health Supervisor. Medication will not be administered without authorization.
Acetaminophen (i.e. Tylenol)	*	Yes No
Anti-inflammatory (i.e. Ibuprofen, Advil, Motrin)	*	Yes No
Gastrointestinal (i.e. Peptobismol, Kaopectate)	*	Yes No
Antacid (i.e. Mylanta, Tums)	*	Yes No
Decongestants (i.e. Sudafed, Robitussin)	*	Yes No
Antihistamine (i.e. Claritin)	*	Yes No
Diphenhydramine (i.e. Benadryl)	*	Yes No
Triple Antibiotic (i.e. Neosporin)	*	Yes No
Pramocaine (i.e. Caladryl Lotion)	*	Yes No
Hydrocortisone Cream (itch/rash)	*	Yes No
Cough Drops (cough)	*	Yes No
Please call before dispensing medication to my camper.	*	Yes No
If Parent/Guardian is NOT available in a case of emergency, please notify and give authorization to pick up my child named above, to the following individuals:
Emergency Contact Name (1)	*
Emergency Contact Home Phone (1)	*
Emergency Contact Work Phone (1)
Emergency Contact Cell Phone (1)
Emergency Contact Name (2)	*
Emergency Contact Home Phone (2)	*
Emergency Contact Work Phone (2)
Emergency Contact Cell Phone (2)
Paintball (an additional fee of $15.00)	*	Yes, I would like to sign my child up for paintball. No, I would not like to sign my child up for paintball.
REFUND/SUBSTITUTION POLICIES: Parent requests for refunds are to be made directly to the school. IHC does not collect or refund any fees directly from parents. IHC has no role in school refunds to parents.	*	I understand and accept the Refund/Substitution policies.
Release, Waiver and Indemnity Agreement
For and in consideration of permitting my son or daughter to observe, or use any facility or equipment of Shiloah Springs Bible Retreat, Inc. d/b/a "Indian Hills Camp" ("IHC"), or engage in and/or receive instruction in any activity or activity incidental thereto some of which may involve danger, risk of bodily injury, or death at Indian Hills Camp, I hereby voluntarily and absolutely release, discharge, waive, and relinquish any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to my child as a result of my child's observing or using facilities or equipment of Indian Hills Camp, engaging in or receiving instructions in any activities some of which may involve danger, risk of bodily injury, or death or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. I, as parent or guardian of my child for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Indian Hills Camp or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless Indian Hills Camp and its officers, agents, servants, or employees from any and all claims or causes of action, including attorney's fees, by my child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will I present any claim against Indian Hills Camp and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by Indian Hills Camp and said persons. By signing below, I represent that I have read this release, have requested and have been provided with, or have requested and declined advisement on the potentials dangers/risks or engaging in the observation, activities, or instruction offered, and am fully aware of and understand the terms and the legal consequences of the signing of this Release. I intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. In addition to the Release set forth above, as parent/legal guardian of my child I hereby grant permission to Indian Hills Camp to take photographs of my child throughout my child's stay at Indian Hills Camp. I understand that all photographs taken of my child are the sole property of Indian Hills Camp and may be psoted on Indian Hills Camp's website and promotion and advertising activities of Indian Hills Camp.
Release, Waiver, and Indemnity Agreement	*	I accept, understand and agree with all of the above terms.
Authorization for Treatment
I am the parent or legal guardian of the minor named in the "Camper Name" fields above (hereinafter "my child").
My child is attending and participating in activities at Shiloah Springs Bible Retreat, Inc. d/b/a "Indian Hills Camp" (hereinafter "Indian Hills Camp") located at: 15763 Lyons Valley Road, Jamul, CA 91935, in the County of San Diego, or other Indian Hills Camp designated location. I hereby authorize the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp, who supervise the activities at Indian Hills Camp into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code. The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further authorize the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp, who supervise the activities at Indian Hills Camp to receive physical custody of my child, under Section 1283(a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the officers, agents, servants, or employees that are 18 years of age or older of Indian Hills Camp who supervise the activities at Indian Hills Camp. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.
Authorization for Treatment	*	I accept, understand and agree with all of the above terms.
Parent/Guardian First Name	*
Parent/Guardian Last Name	*
Please enter your name here to sign this release.
Parent/Guardian Electronic Signature (please enter full name)	*
Security Code	*
Thank you for completing the Registration Request process. A form successfully submitted will redirect you to a Thank You page on the Indian Hills Camp website. If you are not redirected to a thank you page, your form has not been successfully submitted. Please ensure that all fields are completely and correctly filled out if not redirected.