Boys Camp
2017
Boys Camp 2017
REGISTRATION PACKET
Circle Six Ranch Baptist Camp
2784 St. Hwy 137 - Lenorah, TX 79749
432.458.3467 - 432.458.3320 (FAX)
www.circle6ranch.org - [email protected]
YOU HAVE SENT YOUR DEPOSITS,
NOW WHAT DO YOU DO?
Here is a CHECKLIST of what we need Before June 23rd.
1. Church recommendation form
2. Substitution, Addition, and Cancellation Form (if needed)
3. registration / Medical release forms
4. housing list
5. T-Shirt Order form
6. Criminal History Check / Sex offender Check
7. Child Protection certificates
Upon Arrival at camp, these items are needed.
1. Final Payment
2. Medical Administration Forms/ Medications
Registration Packet Instructions
1. Housing List (Please list all males/females attending camp including sponsors). It is important that this list be
accurate to ensure a bed space, t-shirt, and name tag for each person.
2. T-Shirt Form: To ensure the correct quantity and size of the themed t-shirt for your group, please indicate the
desired quantity of each size.
FORMS REQUIRED BY STATE OF TEXAS: These documents are required for every person
age 18 and over attending camp. These documents must be mailed, faxed or emailed to
Circle Six. We are required by law to have an actual copy of the background and sex offender
checks.
3. Criminal Background Check: A criminal background check is required by the State of Texas. This report
must be current and completed within the last 365 days of the last day of your session of camp. A criminal
background check may be performed online at www.records.txdps.state.tx.us for a nominal charge. It is
important that you register as an organization that provides Volunteer Children’s Activities to get this for a
nominal fee. It is the sponsoring churches responsibility to perform these checks and submit proof of proper
documentation. Sex Offender Check: A sex offender check is required by the State of Texas. This report must be
current and completed within the last 365 days of the last day of your session of camp. A sex offender
background check may be performed online at https://records.txdps.state.tx.us/ for no charge. It is the
sponsoring churches responsibility to perform these checks and submit proof of proper documentation.
4. Child Protection Training Certificates: You may download the training materials and certificate from our
website or obtain the DVD by request and $10 prepayment from Circle Six. Everything you need is on the DVD
or online. Plan a time to show the DVD to all adult sponsors. After the video, give out the test and then grade
the test. If the adult satisfactorily completes the test, give them a copy of the completed certificate (also on the
DVD). Make two photo copies of each Child Protection Certificate (one for church and the other for Circle Six).
REQUIRED ORIGINAL DOCUMENTS: These two forms can be filled out online. However,
they must be PRINTED, SIGNED and MAILED to Circle Six. This form is required of EVERY
person attending camp. Original forms MUST be sent to Circle Six. Copies are not permitted.
5. Registration/Medical Release Form (Required for EVERY person attending camp)
6. Church Recommendation Form (Required for EVERY PERSON age 18 and over)
7. Substitution, Addition/Cancellation Form: If necessary, this form is to be used for substitutions, cancellations
and releasing of spots back to Circle Six. If you are not using all spaces secured by your deposits, please
complete the written notification at the bottom of page so that your church will not be held financially
responsible for the balance of unused reservations.
8. MONEY MATTERS: To date you should have sent your church registration form and $35 per camper
deposit. Camp fees are due upon arrival to camp on July 13th.
ADULT SPONSOR LETTER OF CHURCH RECOMMENDATION
Church: _________________________________________________________________________
Phone: (______)______________ Address:_____________________________________________
City: ______________________________________ State: ______ Zip: __________
The following adult(s) will serve as volunteer sponsors for the above stated church group.
Name of Adult Volunteer Sponsor
(Sponsors Must be 19 years of age)
Date of Birth
1. ______________________________
___/___/___
--State Required Documents-Sex Offender
Criminal
Current
Background
History
Training
Check
Background Certificate
Circle Six Office Use Only
____________
__________ ______
2. ______________________________
___/___/___
____________
__________
______
3. ______________________________
___/___/___
____________
__________
______
4. ______________________________
___/___/___
____________
__________
______
5. ______________________________
___/___/___
____________
__________
______
6. ______________________________
___/___/___
____________
__________
______
7. ______________________________
___/___/___
____________
__________
______
8. ______________________________
___/___/___
____________
__________
______
9. ______________________________
___/___/___
____________
__________
______
10. ______________________________ ___/___/___
____________
__________
______
ATTESTATION by the pastor, minister and/or church leader (chairman of the deacons, trustee, etc).
The above named individuals are known to me/us, and I/we can attest to the character, integrity and
ability of each to serve as a sponsor. I/we know of no reason why any should not serve as a sponsor for
children and youth under the age of (18) eighteen. I/we also attest to the fact that each of these sponsors
has undergone a background check as mandated by the State of Texas and has successfully completed the
required Child Protection Training. I/we recommend them to you as persons who will represent our church
or organization in the supervision of our young people.
_________________________________
______________________________
____________
Pastor Signature
Printed Name
Date
_________________________________
______________________________
____________
Church Representative / Position
Printed Name
Date
Refer to the enclosed Bulletin regarding the Texas Department of State Health Services CHILD PROTECTION LAWS and mandatory
requirements for Camp Adult Sponsors. Proper documentation must be submitted with CSRBC Registration Medical/Liability Release
form.
NOTIFICATION OF CAMPER SUBSTITUTION, ADDITION, AND/OR CANCELLATION
If your church group needs to submit a substitution or a pre-registered camper is unable to attend camp, please mail or
fax this notification to the Summer Camp Program Office 432.458.3467 Fax 432.458.3320
Circle Six Ranch PO BOX 976 Stanton, TX 79782
________________________________________________________________________________
Church Name
City
State
________________________________________________________________________________________
Contact Person
Daytime Phone
E-mail
SUBSTITUTION POLICY:
After the session registration deadline, any person enrolling as a substitute must pay an additional $10. Any processed registration fee
for the person they are replacing will be accepted as the substitute’s registration fee, with the additional required $10.
IMPORTANT...Approval for any substitution must be in writing and authorized with the Office before bringing your group to Ignite
Week. We also request, if at all possible, substitutions be the same gender as the person they are replacing. Housing assignments are
made according to gender. Therefore, confirmation of available bed space for any substitution is important prior to arriving at camp.
Substitution or Addition after session deadline:
Medical/Liability Release Form Required
Person added:
OFFICE USE ONLY
T-shirt Size
1.________________________________________________
Substitution For:____________________________________
Person added:
___________
(adult size)
T-shirt Size
1.________________________________________________
Substitution For:____________________________________
___________
(adult size)
___/___/___ Date Received
! Student
Grade Completed
__________
!
! Adult
Addt’l $10 Fee Received
! Medical Form ! Registration
___/___/___ Date Received
! Student
Grade Completed
_________
! Adult
!
Addt’l $10 Fee Received
! Medical Form ! Registration
CANCELLATION POLICY:
Boys Camp Deadline Date: June 23, 2017
1. If cancellation occurs and the CSRBC Program Office receives written notification PRIOR to session deadline date: The nonrefundable $50 deposit may be transferred as a deposit for a substitute camper, or if the full registration fee for the camper canceling was
submitted prior to the deadline and has been processed by the CSRBC Program office ONLY then will the registration fee (minus the $50 nonrefundable deposit) be refunded or the registration paid my be transferred to a substitute camper.
2. If cancellation occurs AFTER the session deadline date: All registration is non-refundable and may not be applied to an outstanding group
balance. However, the registration may be transferred toward payment for an approved substitute camper.
OFFICE USE ONLY
CANCELLATION:
(Person Church is CANCELING without providing a substitute)
1.____________________________________________________
2. ___________________________________________________
Date
Notified
! Student ! Adult
!
Student !
Adult
Registration
Deleted
Medical
Deleted
___/___/___
________
_______
___/___/___
________
_______
WRITTEN NOTIFICATION:
I authorize the CSRBC Program Office staff to release __________ # of reservation(s) initially secured by a $50 deposit. I understand the above
cancellation policy and acknowledge the financial obligation to CSRBC if notification is given after the session final registration deadline.
______________________________
Signature
_______________________
Church Position
____/____/____
Date
Boys Camp
2017
CIRCLE SIX RANCH BAPTIST CAMP
Boys Camp 2017
PO Box 976 Stanton, TX 79782
432-458-3467 432-458-3320 www.circle6ranch.org
MANDATORY STUDENT REGISTRATION FORM
INSTRUCTIONS: Individuals 18 years of age or younger - Complete the Student Registration form in its entirety. Parent or legal guardian
signature is required. All requested information is applicable.
Type or print legibly in dark ink.
Camper’s Name:______________________________________________________________________________________________________
First
Middle
Last
(indicate name used)
Mailing Address: _____________________________________________________________________________________________________
Street
Birth Date: _____/_____/_____
Mo.
Day
Apt.#
Age now:_____
City
State
Zip
Sex(F/M):____ Grade Completed 2017:______ T-Shirt (youth or adult size):________
Year
Home Phone:(______)____________
Email:_____________________________ Social Security#:_________________________________
Have you been convicted of a felony: !
Yes !
No
If yes, explain: ___________________________________________________________
Name of a Church or Group with whom you are attending: ___________________________________City:________________St:__________
Parent/Legal Guardian: __________________________________________Relationship to you: _____________________________________
Parent/Legal Guardian Phone Number: Daytime (______)____________ Evening (______)____________ Other (______)____________
Parent Email: ________________________________________________
AGREEMENT TO ATTEND, PARTICIPATE,
ASSUMPTION OF RISK AND LIABILITY WAIVER
CIRCLE SIX RANCH BAPTIST CAMP herein after referred to as the “Camp” requires a signature for all attendees of the Camp and all participants of any Camp
activity including, but not limited to, Challenge/Ropes Course (highs and lows), Paintball, Swimming Pool, Archery, Rifle Ranges, Camping, Basketball, Baseball,
Softball, Volleyball, and any and all other camp and recreational sports and activities. Furthermore this form releases the Camp to photograph and/or use photographs
of myself or my child for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and
activities of Camp. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to attend Camp and to
participate in any Camp activity.
Attendance and Activities at Camp may include warm-ups, games, group initiative problems, high and low challenge course, paintball and/or other rigorous physical
adventure activities as well as exposure to the elements, exposure to animals, snakes and insects. Camp takes all reasonable precautions to ensure you a safe and
enjoyable experience.Parts of the experience, by their nature, can be physically demanding and include varying levels of stress and anxiety, not all of which can be
foreseen. The decision to attend the Camp and the decision to participate in any Camp activity at any level is at all times completely up to the individual’s choice and, if
there is attendance at the Camp and participation at any level of any Camp activity, there is a risk, which must be assumed by each attendee and by each participant.
Although it is the Camp’s goal to maintain the physical, emotional and social safety of each attendee and participant of the Camp, the physical, emotional and social
risks must be assumed by each attendee and participant.
“I understand that attendance at the Camp and participation in any Camp activity may be physically and emotionally demanding. I recognize the inherent risk of
physical and/or emotional injury of attending Camp and participating in any and/or all Camp activities. I understand that each participant must assume the risk of any
injury, physical and/or emotional, and any financial responsibility that could result from attending Camp and participating in any Camp activity. I agree to assume such
risks and such responsibility. I, on my behalf, and on behalf of my heirs and assigns, hereby release, indemnify and hold harmless Circle Six Ranch Baptist
Camp from any and all claims, physical and emotional, including bodily injury, that I may have that may be sustained in connection with my attending Camp
and with my participation in any and/or all Camp activities.”
If you feel that there are any activities in which you or your child should not be involved in, please describe for us on an attached sheet the activities (include name and
church/group name on the attached sheet.) I understand the directors of Circle Six Ranch Baptist Camp reserve the right to dismiss, without refund, any camper whose
influence is detrimental to the operation of the camp, as determined by the discretion of the directors. I understand that the use of alcohol, tobacco products, and illegal
drugs is strictly prohibited at all Circle Six Ranch Baptist Camp programs.
I have read the Camp rules and agree to abide by all established regulations. I further understand that if I disregard the Camp rules that I will be dismissed and send
home at my own expense. I understand that I will be held financially responsible for any property damage I might cause.
I have read (or had read to me) this complete document and I understand the information contained herein. I have freely and voluntarily signed this document. I
authorize my son/daughter to participate in all camp activities, unless written notification attached specifies otherwise.
X _____________________________________________
Required Parent or Guardian Signature
____________
Date
X _____________________________________________
Required Student Camper’s Signature
PAGE 1 OF 3
____________
Date
Student Registration Form / General Camp Rules
1. All medications are to be listed on the Registration/Medical Release form, registered with the CSRBC medical staff and taken to the Health
Center. All medications must be in original bottle and/or container. Medications will be administered as per RX label instructions and dosage,
unless written, signed, and dated parental instructions state otherwise. A completed Medication Administration Form should be provided with the
medications. Guests are not to share any medications, including over-the-counter medications.
2. Guests who are ill or injured must be either in the CSRBC camp office, medical clinic, or hospital. In the event of illness or injury, students will
not be permitted to remain in their dorm rooms.
3. Prank supplies are not allowed in the dorms (i.e. shaving cream, body paint, water balloons, water guns). There are no exceptions.
4. Adult supervision is required at the pool. At no time is a student to go to the pool without adult supervision.
5. Drugs, alcohol, any form of tobacco, firearms, knives, or any kind of weapon, matches or fireworks are NOT allowed.
6. Guest should not bring the following to camp:Cell phones, iPods, mp3 players, video games, CD players, television, laptop computer, play station
or any other type of electronic games or equipment should not be brought to camp. Keepsake or valuable jewelry, collectible or memorabilia
sportswear should not be brought to camp. CSRBC will not be responsible for the misplacing or theft of guest personal property.
7. Skateboards, rollerblades, Heely roller shoes are NOT allowed
8. Guests are discouraged from bringing food items. Snacks will attract ants in the dorms. We suggest that if you bring snacks, that the food be
stored in tightly sealed containers, such as a plastic storage container or zip-lock bags. No electric appliances to be used for food preparation are
allowed. The CSRBC concession stand will be open throughout the day and each evening.
9. Guests (students and adults) are expected to reflect a Christian example by their dress. Sponsors, parents, and church leaders are responsible
for the clothing and appearance of the youth and adults attending camp. This manner of dress should be set and clearly communicated prior to
leaving home. Modest skirts, dresses, shorts and jeans are acceptable in worship. Immodest short shorts or tops, tank tops, tight clothes, spaghetti
strap tops, distasteful designs or messages, cheer shorts and other extreme clothes are not acceptable at any time. Shorts must be longer than the
arm and hand when extended down the side of the person. One piece swimsuits are preferred. Anything else will require a dark colored t-shirt to
be worn over them at all times, including while in the water. Campers may be asked to change their attire if an adult or CSRBC staff feels their
dress is inappropriate.
10.Refrain for Public Displays of Affection with others.
11.Under NO circumstances are girls to be in guys rooms or guys in girls rooms.
12.No fighting or inappropriate / profane language is allowed.
13. Students are to respect all adult leaders and follow their instructions. All adults-members of the CSRBC leadership team, church leadership
teams, and adult volunteers - are in places of authority over all students. They have been trained in how to guide students for each particular event.
14.Everyone must attend all scheduled events. If your group is in an activity, whether in the classroom or on the athletic field, you must be with
them. There are no exceptions to this unless you are injured or sick and are in the CSRBC Health Center, doctor’s office, or hospital.
15.Guest MUST be in the dorm by designated camp curfew. Your curfew is for your security and for your mental and physical well-being.
16. Guest must wear name tags at all times. Each Boys Camp participant will be issued a name tag upon arrival, which is to be worn during all
meals, and other activities during the day. Name tags are required at the Health Center before a camper can be given medical attention,
17.Guests are not allowed to leave Circle Six Ranch Baptist Camp without proper parental written authorization and approval of CSRBC
administrative staff.
18.Guest are not allowed to bring pets on campus. No pets in the dorms, motels, or meeting rooms.
19.Guest and/or church group leadership will be held financially responsible for any property damages that occur during their stay at CSRBC.
Campers should refrain from writing on furniture or walls. Do not use duct tape to secure signs to doors or walls.
20.For your safety, guests are not allowed on any CSRBC “Restricted” property areas.
Parental Authorization for Early Release (Only fill out if your child will leave camp early.)
It is understood that my child will return home with the church group he/she arrive with. In the event that my child needs to be released
early he/she may be released to the following persons. If a camper is to be released from camp early, both the camper and adult picking up
the camper MUST officially check out through the main office or Health Center. Proper identification is required.
Name
Relationship
Driver License No.
Contact Number
____________________________
_____________________
______________________
(____)_________________
____________________________
_____________________
______________________
(____)_________________
Reason for early release: __________________________________________________________________________________
PLEASE DO NOT RELEASE MY CHILD TO:
Name
Relationship
____________________________________
________________________
X __________________________________________
Required Parent or Legal Guardian Signature
______________
Date
PAGE 2 OF 3
MANDATORY STUDENT MEDICAL RELEASE FORM
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.
Camper’s Name: ___________________________________________________ Birth Date: _____/_____/_____ Age: _______ Sex:(M/F)_______
First
Middle
Last
Mo.
Day
Year
Church: ____________________________________________ City:__________________ Dates at C6: _____/_____/_____ 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
Significant Allergies (specify)
Food: _____________________________________________________
Insect Sting: _______________________________________________
Medicine/Drug: _____________________________________________
Plant/Pollen: _______________________________________________
Other: ____________________________________________________
Diseases, Chronic or Recurring Illness: (Check all that apply, explain)
Asthma: _____________________________________________
Bleeding Disorder: _____________________________________
Dermatological Condition: _______________________________
Diabetes: ____________________________________________
Ear Infections: ________________________________________
Heart Defect: _________________________________________
Seizures: ____________________________________________
Stomach Condition: ____________________________________
Emotional: ___________________________________________
Other: _______________________________________________
Special Diet: _________________________________________________
Recent Surgery? ______________________________________________
Date of last Tetanus Shot? ______________________________________
Current Immunizations? ________________________________________
State law requires all medications to be placed in the campus Health Center. All medications must be brought in the original container (prescription
or over-the-counter) properly labeled as prescribed by law. Prescription labels must have the camper’s name and current dosage. A current
Medication Administration Authorization Form MUST accompany all medication. Medications and Administration instructions will be collected and
reviewed by CSRBC Medical staff upon camper arrival. CSRBC Medical staff requests that you NOT send over the counter medications such as
Tylenol, Ibuprofen, Benadryl, or antihistamines. CSRBC stock an assortment of over the counter medications for the occasional need.
HEALTH CARE AND CAMP PERMISSION- ALL PARENTS/GUARDIANS MUST INITIAL & SIGN THE STATEMENTS BELOW.
___ I give my 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 the part of my child/ward, 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 my child/ward in consultation with the Camp Health Supervisor and/or the medical director’s standing orders to be given
the following medications as indicated by checking below.
___ acetaminophen (i.e. Tylenol)
___ Ibuprofen (i.e. Advil)
___ decongestant (i.e. Sudafed)
___ antihistamine (i.e. Benadryl, Claritin)
___ antihistamine cream
___ antibacterial ointment
___ antacid tablet (i.e. Tums)
___ additional medications as indicated/prescribed by the CSRBC Medical Director
I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that my child/ward is in acceptable
health, physical ability, and emotionally ready to fully participate in camp. I grant my permission, as the parent/guardian of the camper mentioned on this
form, to participate in all activities associated with the enrolled event with the exceptions of those that are noted.
Please
check which applies:
I, ______________________________ being the legal guardian of ______________________________
OR
I, ______________________________ attending Camp as an 18 year old “CAMPER”
give my permission to Circle Six Ranch Baptist Camp’s management, medical staff, and/or the group director to provide medical treatment that may be
deemed necessary to insure the well-being of the named student. 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 Circle Six Ranch Baptist Camp sponsored activities.
X _____________________________________
Required Parent or Legal Guardian Signature
____/____/____
Date
X _____________________________________
Required Signature of Student CAMPER 18 years-older
PAGE 3 OF 3
____/____/____
Date
Boys Camp
2017
CIRCLE SIX RANCH BAPTIST CAMP
Boys Camp 2017
PO Box 976 Stanton, TX 79782
432-458-3467 432-458-3320 www.circle6ranch.org
MANDATORY ADULT REGISTRATION FORM
INSTRUCTIONS: Individuals 18 years of age or older - Complete the Adult Registration form in its entirety. All requested information is
applicable. Type or print legibly in dark ink.
Adult’s Name:______________________________________________________________________________________________________
First
Middle
Last
(indicate name used)
Mailing Address: _____________________________________________________________________________________________________
Street
Birth Date: _____/_____/_____
Mo.
Day
Apt.#
Age now:_____
City
State
Zip
Sex(F/M):____ T-Shirt (adult size):_____ Social Security No.:___________________
Year
Phone Number: Daytime (______)_______________ Evening (______)______________ Other (______)________________
Email:_____________________________ Occupation::________________________________ Employer: ____________________________
Have you been convicted of a felony: !
Yes !
No
If yes, explain: ______________________________________________________
Name of Church or Group with whom you are attending: ______________________________ City: _____________________ St: __________
AGREEMENT TO ATTEND, PARTICIPATE,
ASSUMPTION OF RISK AND LIABILITY WAIVER
CIRCLE SIX RANCH BAPTIST CAMP herein after referred to as the “Camp” requires a signature for all attendees of the Camp and all participants of any Camp
activity including, but not limited to, Challenge/Ropes Course (highs and lows), Paintball, Swimming Pool, Archery, Rifle Ranges, Camping, Basketball, Baseball,
Softball, Volleyball, and any and all other camp and recreational sports and activities. Furthermore this form releases the Camp to photograph and/or use photographs
of myself or my child for use in its publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and
activities of Camp. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to attend Camp and to
participate in any Camp activity.
Attendance and Activities at Camp may include warm-ups, games, group initiative problems, high and low challenge course, paintball and/or other rigorous physical
adventure activities as well as exposure to the elements, exposure to animals, snakes and insects. Camp takes all reasonable precautions to ensure you a safe and
enjoyable experience.Parts of the experience, by their nature, can be physically demanding and include varying levels of stress and anxiety, not all of which can be
foreseen. The decision to attend the Camp and the decision to participate in any Camp activity at any level is at all times completely up to the individual’s choice and, if
there is attendance at the Camp and participation at any level of any Camp activity, there is a risk, which must be assumed by each attendee and by each participant.
Although it is the Camp’s goal to maintain the physical, emotional and social safety of each attendee and participant of the Camp, the physical, emotional and social
risks must be assumed by each attendee and participant.
“I understand that attendance at the Camp and participation in any Camp activity may be physically and emotionally demanding. I recognize the inherent risk of
physical and/or emotional injury of attending Camp and participating in any and/or all Camp activities. I understand that each participant must assume the risk of any
injury, physical and/or emotional, and any financial responsibility that could result from attending Camp and participating in any Camp activity. I agree to assume such
risks and such responsibility. I, on my behalf, and on behalf of my heirs and assigns, hereby release, indemnify and hold harmless Circle Six Ranch Baptist
Camp from any and all claims, physical and emotional, including bodily injury, that I may have that may be sustained in connection with my attending Camp
and with my participation in any and/or all Camp activities.”
If you feel that there are any activities in which you or your child should not be involved in, please describe for us on an attached sheet the activities (include name and
church/group name on the attached sheet.) I understand the directors of Circle Six Ranch Baptist Camp reserve the right to dismiss, without refund, any camper whose
influence is detrimental to the operation of the camp, as determined by the discretion of the directors. I understand that the use of alcohol, tobacco products, and illegal
drugs is strictly prohibited at all Circle Six Ranch Baptist Camp programs.
I have read the Camp rules and agree to abide by all established regulations. I further understand that if I disregard the Camp rules that I will be dismissed and send
home at my own expense. I understand that I will be held financially responsible for any property damage I might cause.
I have read (or had read to me) this complete document and I understand the information contained herein. I have freely and voluntarily signed this document. I
authorize my son/daughter to participate in all camp activities, unless written notification attached specifies otherwise.
X _____________________________________________
Required Adult Attendee/Participant Signature
____________
Date
PAGE 1 OF 3
Adult Registration Form / General Camp Rules
1. All medications are to be listed on the Registration/Medical Release form, registered with the CSRBC medical staff and taken to the Health
Center. All medications must be in original bottle and/or container. Medications will be administered as per RX label instructions and dosage,
unless written, signed, and dated parental instructions state otherwise. A completed Medication Administration Form should be provided with the
medications. Guests are not to share any medications, including over-the-counter medications.
2. Guests who are ill or injured must be either in the CSRBC camp office, medical clinic, or hospital. In the event of illness or injury, students will
not be permitted to remain in their dorm rooms.
3. Prank supplies are not allowed in the dorms (i.e. shaving cream, body paint, water balloons, water guns). There are no exceptions.
4. Adult supervision is required at the pool. At no time is a student to go to the pool without adult supervision.
5. Drugs, alcohol, any form of tobacco, firearms, knives, or any kind of weapon, matches or fireworks are NOT allowed.
6. Guest should not bring the following to camp:Cell phones, iPods, mp3 players, video games, CD players, television, laptop computer, play station
or any other type of electronic games or equipment should not be brought to camp. Keepsake or valuable jewelry, collectible or memorabilia
sportswear should not be brought to camp. CSRBC will not be responsible for the misplacing or theft of guest personal property.
7. Skateboards, rollerblades, Heely roller shoes are NOT allowed
8. Guests are discouraged from bringing food items. Snacks will attract ants in the dorms. We suggest that if you bring snacks, that the food be
stored in tightly sealed containers, such as a plastic storage container or zip-lock bags. No electric appliances to be used for food preparation are
allowed. The CSRBC concession stand will be open throughout the day and each evening.
9. Guests (students and adults) are expected to reflect a Christian example by their dress. Sponsors, parents, and church leaders are responsible
for the clothing and appearance of the youth and adults attending camp. This manner of dress should be set and clearly communicated prior to
leaving home. Modest skirts, dresses, shorts and jeans are acceptable in worship. Immodest short shorts or tops, tank tops, tight clothes, spaghetti
strap tops, distasteful designs or messages, cheer shorts and other extreme clothes are not acceptable at any time. Shorts must be longer than the
arm and hand when extended down the side of the person. One piece swimsuits are preferred. Anything else will require a dark colored t-shirt to
be worn over them at all times, including while in the water. Campers may be asked to change their attire if an adult or CSRBC staff feels their
dress is inappropriate.
10.Refrain for Public Displays of Affection with others.
11.Under NO circumstances are girls to be in guys rooms or guys in girls rooms.
12.No fighting or inappropriate / profane language is allowed.
13. Students are to respect all adult leaders and follow their instructions. All adults-members of the CSRBC leadership team, church leadership
teams, and adult volunteers - are in places of authority over all students. They have been trained in how to guide students for each particular event.
14.Everyone must attend all scheduled events. If your group is in an activity, whether in the classroom or on the athletic field, you must be with
them. There are no exceptions to this unless you are injured or sick and are in the CSRBC Health Center, doctor’s office, or hospital.
15.Guest MUST be in the dorm by designated camp curfew. Your curfew is for your security and for your mental and physical well-being.
16. Guest must wear name tags at all times. Each Boys Camp participant will be issued a name tag upon arrival, which is to be worn during all
meals, and other activities during the day. Name tags are required at the Health Center before a camper can be given medical attention,
17.Guests are not allowed to leave Circle Six Ranch Baptist Camp without proper parental written authorization and approval of CSRBC
administrative staff.
18.Guest are not allowed to bring pets on campus. No pets in the dorms, motels, or meeting rooms.
19.Guest and/or church group leadership will be held financially responsible for any property damages that occur during their stay at CSRBC.
Campers should refrain from writing on furniture or walls. Do not use duct tape to secure signs to doors or walls.
20.For your safety, guests are not allowed on any CSRBC “Restricted” property areas.
PAGE 2 OF 3
MANDATORY ADULT MEDICAL RELEASE FORM
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 of Adult Sponsor:____________________________________________ Birth Date: _____/_____/_____ Age: _______ Sex:(M/F)_______
First
Middle
Last
Mo.
Day
Year
Church: ____________________________________________ City:__________________ Dates at C6: _____/_____/_____ 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
Significant Allergies (specify)
Food: _____________________________________________________
Insect Sting: _______________________________________________
Medicine/Drug: _____________________________________________
Plant/Pollen: _______________________________________________
Other: ____________________________________________________
Diseases, Chronic or Recurring Illness: (Check all that apply, explain)
Asthma: _____________________________________________
Bleeding Disorder: _____________________________________
Dermatological Condition: _______________________________
Diabetes: ____________________________________________
Ear Infections: ________________________________________
Heart Defect: _________________________________________
Seizures: ____________________________________________
Stomach Condition: ____________________________________
Emotional: ___________________________________________
Other: _______________________________________________
Special Diet: _________________________________________________
Recent Surgery? ______________________________________________
Date of last Tetanus Shot? ______________________________________
Current Immunizations? ________________________________________
State law requires all medications to be placed in the campus Health Center. All medications must be brought in the original container (prescription
or over-the-counter) properly labeled as prescribed by law. Prescription labels must have the camper’s name and current dosage. A current
Medication Administration Authorization Form MUST accompany all medication. Medications and Administration instructions will be collected and
reviewed by CSRBC Medical staff upon camper arrival. CSRBC Medical staff requests that you NOT send over the counter medications such as
Tylenol, Ibuprofen, Benadryl, or antihistamines. CSRBC stock an assortment of over the counter medications for the occasional need.
HEALTH CARE AND CAMP PERMISSION- INITIAL & SIGN THE STATEMENTS BELOW.
___ I give my 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 the part of my child/ward, 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 my child/ward in consultation with the Camp Health Supervisor and/or the medical director’s standing orders to be given
the following medications as indicated by checking below.
___ acetaminophen (i.e. Tylenol)
___ Ibuprofen (i.e. Advil)
___ decongestant (i.e. Sudafed)
___ antihistamine (i.e. Benadryl, Claritin)
___ antihistamine cream
___ antibacterial ointment
___ antacid tablet (i.e. Tums)
___ additional medications as indicated/prescribed by the CSRBC Medical Director
I hereby attest that all information listed on this Medical Form is complete and accurate to the best of my knowledge that I am in acceptable health,
physical ability, and emotionally ready to fully participate in camp. I grant my permission to participate in all activities associated with the enrolled event
with the exceptions of those that are noted.
i, _______________________________________ give my permission to Circle Six Ranch Baptist Camp’s management, medical staff, and/or the
group director to provide medical treatment that may be deemed necessary to insure the well-being of the named student. 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 Circle Six Ranch
Baptist Camp sponsored activities.
X _____________________________________
Adult Sponsor/Leader Signature
____/____/____
Date
(_____)_____________________
Phone Number
PAGE 3 OF 3
Boys Housing List
This information is required no later than June 23rd.
This form is very important and used for multiple purposes such as housing and nametags.
Please print legibly or type information.
Keep a copy of this form for your files to be used in submitting possible late registrants or substitutions. A completed and signed Adult & Student
Registration / Liability Waiver and Medical Release Form must be provided for each camper and sponsor listed below.
Required Adult Sponsor to Camper ratio is 1:8
Please print neatly, nametags will be made from this list.
Boys Name
Grade completed
May ’17
T-shirt size
1
2
3
4
5
6
7
8
9 Sponsor
Age________
10
11
12
13
14
15
16
17
18 Sponsor
Age________
19
20
21
22 Sponsor
Age ________
ALL Sponsors MUST be 19 years of age or older. Anyone under 19 years of age will count in your student ratio.
Total Male Sponsors: ________________
Total Boys: ________________
Medication Administration Form
Circle Six Ranch Baptist Camp requires that all campers who bring medication to camp comply with the following:
Complete this Medication Administration Form in its entirety. If camper is under 18 years of age, the signature of their parent or legal
1.
guardian is required for administration of medication.
All medication (prescription or over the counter), must be in the ORIGINAL CONTAINER properly labeled as prescribed by law.
2.
Present this form AND the medication listed to the CSRBC Medical Staff upon arrival on campus and abide by his/her instructions for
3.
administration.
CURRENT MEDICATION INFORMATION
Name: ___________________________________________________ Birthdate: ____/____/____ Age:____ Sex: ! Male ! Female
Church group that you came with: _________________________________ Church City & State: _______________________________
As the parent or legal guardian of the above-named child, I give my permission to the enlisted Circle Six Ranch Baptist Camp Medical Staff to
administer as prescribed by law the listed below medication to my child.
_______________________________________________________
____________
Parent/Guardian Signature
Date
(_____)__________
Daytime Phone
(_____)__________
Evening Phone
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: _______________________________________________________________________________________
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
Administration Forms and medication(s) to be administered should be given to the church Contact Person prior to arriving at camp. DO NOT PUT
MEDICATION IN YOUR SUITCASE. When the church group arrives at camp, the Contact Person will be responsible for bringing all medications
and forms to the camp registration area. 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 RX bottles of medications and Medication Form 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)
their responsibility of reporting to the camp Health Center for their medications while at camp.
T-Shirt Order Form
T-shirts cannot be guaranteed for guests unless this form is received by the camp office no later than June 23, 2017.
Church Name: _________________________________________ City & State: ______________________
Group Contact Person: ___________________________________ Phone Number: (____)_____________
Total Number of Guests in Group (student and sponsor): ________
Size
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Adult Double XL
Adult Triple XL
Quantity