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Holy Korean Martyrs Catholic Church

5801 Security Boulevard, Baltimore, MD 21207

Dear Camper and Parents, Holy Korean Martyrs Catholic Church will be sponsoring its annual Summer Camp. Like every year, we hope this Summer Camp will be a time of fun and spiritual growth for everyone. But we also want to make sure this is a safe and pleasant experience for all campers. Attached you will find a permission and release form, a behavior guidance form, and a personal health and medical history form.

GENERAL INFORMATION Who: Students (7th 12th Grade) Where: Camp Summit Lake 7610 Hampton Valley Road Emmitsburg, MD 21727 Date: August 13th 16th, 2012 Cost: $190 (checks made payable to HKM) Meet: Holy Korean Martyrs Catholic Church Monday, August 13, 2012 8:00 A.M. Arrive: Holy Korean Martyrs Catholic Church Thursday, August 16, 2012 5:30 P.M. Bring: Bible & Rosary Sleeping Bag & Pillow

Change of Clothing for 3 Days (bathing suit, warm clothes, & clothes to get dirty) FLASHLIGHT Toiletries (shampoo, soap, towels etc.) Name (English, Korean): Grade:

Gender: F

Student E-mail:

Parent Name: Home #: Address: Language: English Both

Work #:

Cell #:


Shirt Size: XS XL


To be filled out by parent or guardian. Please print in ink. IDENTIFICATION If person named above is not available in the event of an emergency, notify: Name:_______________________________ Relationship:_______________________ Phone:___________________ Name:_______________________________ Relationship:_______________________ Phone:___________________ Name of Personal Physician:_____________________________________________ Phone:___________________ Personal health/accidental insurance carrier:___________________________ Policy#:________________

Check all items that apply, past or present, to your health history. Explain and yes answers. Allergies: Food, Medicines, insects, plants, etc. Yes ( ) No ( ) Explain:_________________________ General Information: Asthma Convulsions/seizures Diabetes ( ) Dietary Restrictions Yes ( ( ( ( ) ( ) ( ) ( ) ( No ) ) ) ) Heart Trouble Hemophilia Yes No ( ( )( )( ) ) )

High Blood Pressure(

Other:_______________________________________________________________________ Explain:______________________________________________________________________ Please list ALL medications taken in the 30 days prior to arrival at the retreat site:___________________________________________________________________________ ________________________ List any medications to be taken at retreat, including drugs, dosage, route (oral, injection, etc.) and frequency: _______________________________________________________________________________ _______________________________________________________________________________ ________________ List any physical or behavioral conditions that may affect or limit full participation in playing strenuous physical games:_________________________________________________________________ _______________________________________________________________________________ __________________________

I give permission for full participation in programs subject to limitations noted herein. In case of emergency, I understand every effort will be made to contact me. IN the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner selected to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. I understand the staff will do its best to assure all possible safely measures for my child. I recognize that Holy Korean Martyrs Catholic Church (HKM) will not be held liable for any accident or injury during the retreat. In the event of injury to my child, HKM is not responsible for reimbursement of medical expenses resulting from injury.

In consideration of the wholesome recreational and learning experience in which my son/daughter will participate, I, as a parent or guardian of my son/daughter, do hereby agree to allow my son/daughter to accompany the youth ministry group of their parish to: Summer Camp, August 13, 2012 to August 16, 2012.

In consideration of the opportunity for my son/daughter to participate in the program, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY Holy Korean Martyrs Catholic Church (HKMCC), the youth and Young adult ministry, the Roman Catholic Bishop of Baltimore and his successors, a Corporate Sole, and all their agents, servants and employees from any liability, claims, demands and causes of action arising out of or relating to any loss, damage, or injury sustained in connection with or arising out of my son/daughters participation in the program.

Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites, or other materials produced from time to time by HKMCC. (Participants would not be identified, however, without specific written consent.) Parents/guardians who do not wish their child(ren) to be photographed or filmed should notify HKMCC in writing. In order to guarantee a safe, positive, and enjoyable environment for your child as well as the other children in the retreat, we have established guidelines for all campers. We are here to plain and lead activities that are safe, creative, and fun for the campers. Therefore no childs behavior should interfere with our ability to carry out this program, hinder another childs right to enjoy being here, or go against the best interest of him/herself or the group. Rules: 1. Be respectful to others, self, counselors, and staff. 2. Be respectful of environment (property, supplies, and equipment).

3. Follow Directions I, the parent/guardian, understand that if my child does not follow these rules, disciplinary actions will be taken and if necessary, the child will be asked to leave the retreat as soon as possible.

By signing below, I, the parent/guardian understand and agree to ALL conditions stated in this document.