CampAnderson

Monday April 2nd- Saturday April 7th

Pinecrest Baptist /Creekside Academy

Christian Camp & Retreat

CampAnderson

CampAnderson

Presents....

Camp

Activities

Paint Ball

Snorkeling

The “Blob”

Shrimpin’ with Captain Buddy

Camp Fire Cookout

Fishing

Shired Island Beach

“Deuce and a Half”

Dynamic Speakers

Excellent Music

Camp Fire Cookout

Great CounselorsCamp Anderson Sheriff

Cowboy the Camp Dog The Blues Brothers

Our Mission Project for the Week will be to seed the community and hand out flyers for the upcoming Evangelistic Youth Rally!

Camp Anderson Location

Camp Anderson is located on the beautiful Suwannee River about 20 miles from the Gulf of Mexico. This area of the river is fed by the largest number of freshwater springs in the world and attracts abundant wildlifeincluding manatees that come up into the river to enjoy the constant 72 degree spring water. The camp location is on a wide section of the river and has breathtaking beauty. The riverbank is covered with mossladen cypress trees that are hundreds of years old.The camp area is unique in that it is near the beach and ocean oriented activities as well as the river with the springs, fishing, snorkeling and water sport activities. The weather is mild and provides opportunities for camp well into the winter months. The surrounding area is the small town of “Old Town” and the residentsenjoy the small town USA sense of community.The Camp has good accommodations including 9 log cabins that sleep 6 each, main camp building with game room, dining and shower facilities. There is a large covered pavilion that will seat up to 300. In ground poolRV hook ups, and about 1500 ft. of unspoiled beautiful riverfront. The physical Address for the camp is 101 KOA Rd. Old Town Fl. 32680Contact: William Bloodworth 770-598-6896

Pinecrest / Creekside Camp Anderson Registration Form Transportation to and from camp will be the responsibility of Parent or Guardian or Sponsoring Church. Camp Physical Address is: 1 KOA Rd. Old Town Florida. Contact William Bloodworth (Camp Director) 770-598-6896 cell wbloodworth@campanderson.org Mailing Address: 494 Covered Bridge Rd. Covington, Ga. 30016 Registration and deposit payment of $75 due 30 days before the beginning of camp. Camp is limited to 45 campers per week, first come first served.

Name of Camper: _________________________Age____ Height ___Weight ___Gender___ Please rate your Camper regarding Physical or Athletic ability: ______________________ Camper’s Phone Number ___________________Campers Email Address___________________ Name of Legal Guardian_________________________ Phone # ______________________ Address______________________________ Email Address___________________________ Church Affiliation if any: ________________________________________________________

Camp Anderson may offer any or all of the following events (Please check the box for all activities that your camper has permission to participate in. If the box is not checked, the camper will not be permitted to participate.) _____Kayaks/Canoes _____Paint ball _____Marksmanship (Includes Gun safety with .22 caliber rifles) _____Swimming / Snorkeling (Swimming Pool, River and Ocean at the Beach) _____Water Blob (water trampoline) _____Tubing behind power boat _____Shrimp Boat Trip (Involves riding on a shrimp boat within approx. 10 miles of land). _____Scalloping Trip (Involves riding on a boat within approx. 10 miles of land). I would like to be assigned to the following Counselors at camp if possible._____________________. I would like to room with the following camper ___________________________if possible. Things to Bring to Camp:

1. Sleeping Bag and pillow. 2. Old Clothes include long pants in addition to shorts. 3. Old Tennis shoes (no flip flops). 4. A Bible with Old and New Testament. 5. Bug Spray 6. Sunscreen. 7. Towel and Basic toiletries. 8. Pocket flashlight or headlamp. 9. Modest Swimwear (Girls one piece or tankini) 9. Snorkel Mask 10. Canteen spending money. 10. Fishing Pole if you would like to bring your own, (camp will provide fishing gear).

Things Not to Bring to Camp: 1. This is and “Un-Plugged” camp. Please do not bring Computers, MP3 players, Electronic games, etc. (Cell

phones are OK to bring but they can only be used at free time session as directed by counselor. 2. All Cell phones to be kept in the cabin at all times. 3. Magazines, Drugs, Alcohol, Fireworks, matches, lighters, knives, guns or weapons. 4. Obscene material or t-shirts. 5. Paint Ball equipment and supplies, .22 rifles (these things will be provided by the camp).

Camp Costs: (please fill in the boxes) Camp Fee varies from week to week dependent on program. 1. Camp Fee, covers cost of program, room, board and tee shirt. (adult sizes) Please state Qty.___

Size______(S,M,L, XL, XXL) 2. Spending Money….Camper may want to bring spending money for the Camp Canteen.

Camp Payment Options: (Please check all that apply and fill in the blanks.) _____I am paying the full camp fee on line with a credit card at this time. (www.campanderson.org) _____I will make the minimum payment of $75 on line to secure my place at camp and I will pay the Balance by the first week of camp. _____I will mail or hand-deliver my payment. Make checks out to: William Bloodworth and deliver to

William Bloodworth Mailing Address: 494 Covered Bridge Rd. Covington Ga. 30016 ____ I am making a donation of ______________on behalf of ____________________(camper). My name is: _________________________my phone number is___________________

Camp Anderson PARTICIPANT RELEASE OF LIABILITY

AND ASSUMPTION OF RISK AGREEMENT and MEDICAL INFORMATION

***READ BEFORE SIGNING***

I, _______________________________, am a “Participant” in the Camp Anderson program or I am the parent /legal guardian of _______________________________, who is, with my permission, a “Participant” in the Camp Anderson program, sponsored by Pinecrest Baptist, Camp Anderson, and others for my benefit during the 2012 calendar year. In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate and agree that: I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED IN CAMP ANDERSON ACTIVITIES INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns hereby agree to hold Pinecrest Baptist, Camp Anderson and its officers, agents, trustees, land owners, sponsors, volunteers, and employees harmless from and against any and all liabilities, actions, causes of actions, claims, expenses, and damages suffered on account of any injury to me or my property, even injury resulting in death, which I now have or which may arise in the future in connection with my participation in the activities or any activities, acts, or events associated therewith, including but not limited to any transportation provided or involved in such activities. I expressly agree that this Release agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida and Georgia and that if any portion of this Release is held by any court of competent jurisdiction to be invalid or unenforceable, it is agreed that the balance of the Release shall, notwithstanding, continue in full legal force and effect. This Release contains the entire agreement between Pinecrest Baptist, Camp Anderson and me or Pinecrest Baptist, Camp Anderson and the camper, that I am the legal guardian of, and the terms of this Release are contractual and not mere recital. •Many of the Camp related activities provide desirable experiences that are accompanied by inherent risk that are often higher than normal daily life risks. I am aware and understand that participating in activities while at Camp Anderson, including, but not limited to, use of water blob, tubing behind motor boat, snorkeling or swimming in the river, ocean, or swimming pool, Paintball, Marksmanship with .22 caliber rifles, riding in a boat in the river or ocean, wilderness activities, field sports, and all other camp related activities including work related activities, include the potential risk of injury or death. Some of these risk include (but are not limited to), accidents with fire arms, accidents related to swimming or water sports, including drowning, attacks from wildlife in the water and on land, transportation accidents, physical strain related to strenuous field games and work related accidents for volunteers and paid employees. •I understand that it is normal for camps of this nature including Camp Anderson to utilize volunteer staff and staff that is under 18 yrs. old and that these staff members may not have extensive professional training. While Camp Anderson attempts to provide adequate instruction, policies and procedures, there are inherent risk involved with participating in activities and events that include supervision and oversight by non-professional staff members. Some of the risk include injury or death that may be a result of the staff members oversight of potential hazards, lack of judgment in analyzing risk, lack of proper judgment in prevention of risk and other negligent (but not grossly negligent or intentionally wrong) acts. I also am aware and understand that all of the program activities are strictly voluntary and it is my choice to participate in each activity to whatever degree I deem appropriate, after due consideration of the risks, my own physical health, physical abilities and medical condition. •I agree that I am solely responsible for my own participation and for my own physical and emotional well-being. I will not be under the influence of any chemical substance, including alcohol, while participating. The health history presented to the camp is correct to the best of my knowledge. •I willingly and knowingly assume for myself, my heirs, family members, executors, administrators, and assume all risk of physical injury and emotional upset which may occur during or after participating in any aspect of the program and to hold the Camp Anderson sponsors, Land owners, its employees, its volunteers, its instructors, facilitators and agents harmless for any liability arising out of my participation in the program. Should Camp Anderson or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify (to shift the responsibility for payment of damages to someone else) and hold Camp Anderson and its sponsors, Land owners, its employees, its volunteers, its instructors, facilitators and agents harmless for all such fees and costs.

•I authorize the Camp Anderson to have and use photographs, slides and videotapes of the person named above as needed for its records and marketing purposes. •I have had sufficient opportunity to read this entire document. I have read and understand it, and I agree to be bound by its terms. I hereby grant Camp Anderson and its agents, full authority to take whatever action they deem necessary regarding my health in the case of an emergency. I fully release Camp Anderson and its agents from any liability in connection with those decisions. I grant permission for Camp Anderson and its agents to make decision on my behalf for emergency treatment and care. I understand and agree that I am responsible for all medical care expenses incurred to treat the participant’s injuries including, without limitation, physician, hospital, lab drug and devise expenses. The following policies or coverage are available to cover the cost of medical care to treat any injury incurred by the Participant: Insurance Company________________________________________ Policy#__________________________ Insurance Company Ph. #____________________________________ On Behalf of the Participant, the Participant’s parents, and /or legal guardians, I hereby give approval of the above-named participant’s, participation in any and all programs and activities sponsored or provided by Pinecrest Baptist, Camp Anderson, and do hereby waive, release, absolve, forever discharge, and agree to hold harmless Camp Anderson, Pinecrest Baptist Church, William Bloodworth, officials, land owners, organizers, supervisors, participants, volunteers and persons involved in the operation, organization, sponsorship, supervision or participation of these activities, programs and transportation, against any claim or cause of action, of any nature whatsoever, that may be available to the Participant or his/her parent and /or legal guardians, family or others arising out of the Participant’s participation in such programs, activities, or transportation and travel. Camper / Participant Signature____________________________ Print Name_________________________ Date___________ Parent/Legal Guardian Signature___________________________ Print Name_________________________ Date__________ Cell Phone___________________ Home Phone_____________________ Email Address______________________________ Please answer all questions below. If you answer YES to any questions, please explain. 1. Does Participant have any past or current conditions, including injuries, (physical, mental, or psychological) which may affect his or her participation at camp?_____________________________________________________________________________ _______________________________________________________________________________________________________ 2. Are there any activities that Participant will not be able to participate in during camp? (please see the camp activity list).___________________________________________________________________________________________________ _______________________________________________________________________________________________________ 3. Does Participant know how to swim and does he/she have your permission to swim in water that is over his or her head without wearing a life-vest?________________________________________________________________________________ 4. Does Participant regularly take any medications, including all over-the counter medication? Please note that all medications participant will be using at camp must be brought in the original, labeled package._____________________________________ _______________________________________________________________________________________________________ 5. During the past twelve months, has participant seen a professional to address mental/emotional health concerns? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 6. Is there is any additional medical information you think is important or that may affect the participant ability to participate in the camp?______________________________________________________________________________________________ _______________________________________________________________________________________________________ 7. Does participant have any dietary restrictions or allergies?______________________________________________________ 8. Please provide specific instructions for medications to be administered at camp and any other special medical instructions: ______________________________________________________________________________________________________________________________________________________________________________________________________________ Parent/Legal Guardian Signature ______________________________________________Date__________________________