Register for Future Leaders Camp Please use the form below to register your child for Future Leaders Camp. Step 1 of 3 33% Child's Name* First Last NicknameBirthday* Date Format: MM slash DD slash YYYY Gender*MaleFemaleGrade*Grade for the 2019-2020 school yearSelect grade89Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code T-shirt Size*Select sizeYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAllergies?*YesNoIf yes, list allergies*Does your child have ADD or ADHD?*ADDADHDNoMedications?*YesNoIf yes, list medications*Is your child emotionally, behaviorally, intellectually, or physically challenged?*YesNoIf yes, please explain*Does your child have any special circumstances/requests?*YesNoIf yes, please explain*Medical InfoHospital Preference*Insurance Company*Policy NumberCamp WeeksFuture Leaders Camp WeeksWhat weeks are you registering for?*Session 1 June 17-21 – So You Want To Be A Leader? (Intro to Leadership) June 24-28 – Building a Web (Networking) July 1-5** – Living in a Social Media World **No camp Thursday, July 4 July 8-12 – All About the Arts Session 2 July 15-19 – Being the Boss (Lead by Example) July 22-26 – CGH Career Academy (Exploring Career Pathways) July 29-Aug 2 – Every Second Counts (Time Management) Aug 5-9 – Why Me? (Understanding Your Purpose) June 17-21 June 24-28 July 1-5 July 8-12 July 15-29 July 22-26 July 29-Aug 2 Aug 5-9 Total Deposit DueThere is a $25/week non-refundable deposit due at registration to reserve your child's spot at camp. $0.00 Parent/Guardian and Pick Up InfoParent/Guardians listed below will be considered authorized pick-ups for your child.Parent/Guardian #1* First Last Relationship to child*MotherFatherHome Phone #Cell Phone #*Work Phone #Email* Enter Email Confirm Email Parent/Guardian #2 First Last Relationship to childMotherFatherHome Phone #Cell Phone #Work Phone #Email Enter Email Confirm Email Authorized Pick Up InfoIn addition to parent/guardians, please list anyone that you want to be allowed to pick up your child. You do not need to list parents/guardians again.Authorized Pick-up #1 First Last PhoneRelationship to childWould you like to add another authorized pick-up?*YesNoAuthorized Pick-up #2 First Last PhoneRelationship to childWould you like to add another authorized pick-up?YesNoAuthorized Pick-up #3 First Last PhoneRelationship to childWould you like to add another authorized pick-up?YesNoAuthorized Pick-up #4 First Last PhoneRelationship to child Release FormsLiability and Indemnity AgreementI hereby give my permission for my child, named above, to be transported by Community of Hope Ministries on various special event field trips during the course of the summer/track out camp and after school programs. I have been advised that I will be notified of the dates and times of these trips in advance. In consideration of being permitted to utilize the facilities, services and programs of Community of Hope Ministries for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with Community of Hope Ministries, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into Community of Hope Ministries for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER COMMUNITY OF HOPE MINISTRIES FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH COMMUNITY OF HOPE MINISTRIES, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE Community of Hope Ministries, its directors, officers, employees, and agents (hereinafter referred to as “releases”) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with Community of Hope Ministries. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about Community of Hope Ministries premises or in any way observing or using any facilities or equipment of Community of Hope Ministries or participating in any program affiliated with Community of Hope Ministries whether caused by the negligence of the releasees or otherwise. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasee or otherwise while in, about or upon the premises of Community of Hope Ministries and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with Community of Hope Ministries. 4. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND IDENMITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of N.C. and that if any portion thereof is invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The provisions of this Agreement shall survive the undersigned’s and Participant’s use of Community of Hope Ministries facilities and equipment and participation in the program, and trips affiliated with the summer camp and after school programs. The provisions of this Agreement shall be binding upon and inure to the benefit of Community of Hope Ministries, the undersigned, the Participant and their respective heirs, personal representatives, successors, next of kin and assigns. 5. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. Signature*I have read and agree to the Liability and Indemnity AgreementSick PolicyWe do not have the facilities necessary to care for sick children at the center. If your child develops symptoms of illness during center hours, you will be contacted to pick up your child. Emergency contacts will be contacted if parents cannot be reached. Parent response is crucial when a child is ill. In emergency instances, 911 will be dialed. Such emergency instances are convulsions, seizures, body temperatures exceeding 103.0, allergic reactions, loss of consciousness, and other life threatening signs. Please understand that this is a measure that may protect the life of a child. Parent/Guardian must complete medical authorization form before staff can dispense any medication to your child. In order to return to the center, the children must be free of symptoms and free of fever for 24 hours without medication. Bringing children to the center that are not well may cause other children to get sick. We follow recommended personal and environmental hygiene practices and have developed this policy to cut down on the spread of illness, and therefore decreasing the number of lost work days for parents/ guardians. Please let us know right away if your children are exposed to or diagnosed with something communicable, such as measles or chicken pox, so we can alert other parents. Children with contagious diseases shall not return to the center until the disease is cured and has been diagnosed and documented by a physician as not being infectious or contagious. This documentation must accompany children on their first day back from being out ill. I understand and agree that neither Community of Hope nor co-sponsoring organizations or their respective chapters, officers, directors, employees, agents, members or volunteers shall assume or have any responsibility or liability for expenses or medical treatment or for compensation for any injury my child may suffer during or resulting from their participation in the program. I also represent and warrant that I have been advised to seek consultation from my child’s doctor about whether he/she can safely participate in the program and whether there are precautions or limitations to my child’s participation.Signature*I have read and agree to the sick policy.Authorization for Release and Use of ImageIn consideration of using the services and facilities of Community of Hope Ministries, I hereby irrevocably authorize and grant Community of Hope Ministries the following rights: 1. The right to use the likeness (photograph, picture, portrait, sketches and cartoon, and reproductions of the same, in original or modified form) and/or voice (hereinafter collectively known as “Image”) of the minor(s) whose name(s) appear(s) below (hereinafter collectively known as the “Child(ren)” in connection with its marketing materials or for any other legitimate purpose, with or without using the Child(ren)’s name; 2. The right to use, reproduce, publish, exhibit, distribute, and transmitthe child(ren)’s image individually or in conjunction with other Images or printed matter in the production of brochures, motion pictures, television tape, sound recordings, still photography, CD-ROM, and other media; 3. The right to record, reproduce, amplify, and simulate the child(ren)’s Image and all sound effects produced; and 4. The right to copyright, in its own name, works that contain the child(ren)’s image. I hereby waive the right to inspect or approve the child(ren)’s image or any finished materials that incorporate the child(ren)’s image. I understand and agree that nothing in this release shall obligate Community of Hope Ministries to use the child(ren)’s image and neither I, nor the child(ren) will receive any compensation, now or in the future, in connection with the use of the child(ren)’s image. I hereby release and agree to indemnify, defend and hold harmless Community of Hope Ministries and its directors, officers, agents, and employees from and against any and all claims, demands, liabilities, damages, and cause of action, cost and expenses, including, without limitation, attorney’s fees, of whatever kind or nature arising from Community of Hope Ministries use of the child(ren)’s Image, including, without limitation, all claims for libel, slander, defamation, invasion of privacy or right to publicity and misrepresentation. I agree that all such photographs, portraits, pictures, sketches, cartoons and reproductions as well as all negatives, prints, plates, tapes and disks thereof and all other media containing the images, including, without limitation, the copyrights therein, are and shall remain the sole property of Community of Hope Ministries and it successors and assigns, with full rights of disposition thereof. I understand that the acceptance of this release form by Community of Hope Ministries shall not constitute a waiver, in whole or in part, of sovereign immunity or any other statutory or common law rights by Community of Hope Ministries or its directors, officers, agents, or employees. This authorization and release and the rights granted hereunder shall inure to the benefit of Community of Hope Ministries, its affiliates, successors and assigns, their advertising agency(ies), and those authorized by them. I understand that the child(ren)’s rights to access accommodations and services of Community of Hope Ministries shall not be jeopardized in any way by a decision not to sign this release.SignatureI agree to the release authorization for release and use of image for my child.Camp Good Hope Behavioral GuidelinesOur behavioral guidelines are based on the basic premise of respect. Staff and students are expected to respect each other, and to treat the program, classrooms, and facilities with respect. We have established several specific guidelines for behavior. These guidelines enable all participants in the program to have a safe, enjoyable experience and must be followed in order for students to continue in the program. At camp and in general -Use an “inside voice”. Speak quietly and respectfully. -Refrain from eating, drinking, or chewing gum except in designated areas. -Respect each other! It is never appropriate to make fun of or speak negatively to other after school participants, teachers or guests. -Respect other members’ space, physical person, and property. -Be respectful when the instructor or a guest speaker is talking. -Be positive and try new things. Negative behavior and comments are never appropriate. -Help keep the facilities in order by cleaning up any messes made. -No fighting, violence, or horseplay of any kind. On the Bus -Always enter and exit at the front of the vehicle unless specifically directed to do otherwise in the event of an emergency. -Remain in seat belt, car seat/booster at all times except when entering and exiting the vehicle. -No loud talking, yelling, eating or drinking on the vehicle. -Be respectful of the driver and other passengers at all times. -Follow the driver’s instructions at all times. -Keep hands, feet, and other personal items to yourself. -Do not litter. Consequences of Misconduct -First Incident – Conversation with parents -Second Incident - Meet with Director and parents –warning or one day suspension. -Third Incident – Meet with Director and parents – one week suspension. -Fourth Incident – Meet with Director and parents – permanent removal from program. -Severity Clause: In the Case of Severe Misbehavior such as fighting, threatening other students or staff, possession of a weapon, vandalism or destruction, sexual misconduct, or possession of drugs or alcohol, the student must be picked up immediately and may be permanently removed from the program.Signature*I have read and understand the above guidelines for participation in Camp Good Hope. I agree to follow these guidelines and accept responsibility for my actions or my child’s actions. Camp Good Hope Parent HandbookHours of operation: 7:30 am - 6:00 pm. A weather emergency or other emergency, which causes school to be canceled, will also result in canceling Camp Good Hope. If Wake County Schools close early (including cancelling after school activities) Camp Good Hope will also close early. We have this policy for the safety of your children and our staff. We will not issue refunds for days cancelled due to inclement weather. Late Pick Up and Fees: There is a late fee of $1 per minute. This fee will be assessed beginning with the first late pick up. The late fee will be due upon pick-up and can be paid in cash, check, or with a debit/credit card. It is your responsibility to contact your emergency pick-up person if you cannot arrive by the 6:00 pm pick-up time and call the office. Late pick up adversely affects the program since staff must remain until all students are picked up. A camper will be suspended from the program at the discretion of the Director if late fees are not paid and/or the camper is picked up late on more than four occasions. Community of Hope Ministries requires a non-refundable registration fee of $25 per week per child. Staff: We hire passionate, Christian and caring educators who are committed to the program goals of helping children increase their faith as well as decrease negative choices and increase positive choices. A high quality, faith centered staff is our first priority. Each employee must undergo state and local criminal background checks. Students will be divided into groups according to their grades and development. The student to staff ratio is 1:15. Food: Two snacks and lunch will be provided daily except for lunch on Wednesday. Due to being on a field trip, campers must provide their own lunch on Wednesdays. Teaching campers proper nutrition and manners during snack/eating time is always a part of the program. Discipline Policies: The desire of the program is to guide children to proper behavior through positive techniques. It may be necessary to notify the parent if a child’s behavior is detrimental to the program. Participants will be given one day’s suspension after the first warning and one week’s suspension after the second warning. After the third warning, the participant will not be allowed to return to the program. Health Issues: Staff can only dispense medication to your child if a parent/guardian has completed a medical authorization form. There are some medications that staff will not be able to administer (ex: some medications involving needles). Please contact the program director if this causes any difficulty. If a child is sick when entering the program, as determined by the director or other site staff, the child will be made as comfortable as possible and a parent/guardian will be notified. It is the parent/guardian’s responsibility to pick up their child as soon after notification as the parent can safely travel to the program. Sick children will be separated from the rest of the children as much as possible and will never be left unattended. Staff is trained to recognize communicable diseases and will follow the procedure outlined in First Aid training. Fire Arms/Weapons/Drugs: Our policy regarding fire arms, weapons and drugs (alcohol and tobacco) are consistent with Wake County Public Schools. Failure to comply with these standards may include immediate dismissal from our program. Emergency Procedures: If a child has an injury, staff who are trained in First Aid and CPR will attend to the injury. If no further attention is needed, attending staff will fill out an injury report and parents will be provided with a copy of the report. Parents will be asked to sign the injury report and the report will then be placed in the child’s file. If the accident requires attention beyond staff’s training, the child will be transported to the appropriate medical facility as outlined on the enrollment form or 911 will be contacted if necessary. The parent/guardian will immediately be notified. Contact Information: Parents must keep staff informed if their contact information changes. Arrival and Departure: Your child will be checked in by a staff member each morning when you drop them off. Participants will not be allowed to leave the center with anyone but parent or guardian and those listed on the enrollment form. Parents/authorized pick-ups are required to come in to pick up and sign out their child with a staff member in the front lobby. If members are away from the regular activity area, a notice of their location will be posted. If a parent/guardian either attempts to pick up a child or gives permission for someone else to pick up their child and it is determined by staff in the program, that the person picking up the child is in an incapacitated state (either from drugs, alcohol or any other substance) the child cannot be released to that person. The North Carolina State Highway Patrol or other law enforcement agency will be notified if the person proceeds to take the child.Signature*I have read and understand the policies as outlined in the Community of Hope Ministries Camp Good Hope handbook and will explain all site policies and requirements to my child. I understand that I can request a printed copy of the handbook. I agree to comply with the policies contained in the handbook.NameThis field is for validation purposes and should be left unchanged.