Registration form participant’s name: born



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Data03.05.2016
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For office use only

Camp Vista

N3398 Chapel Heights Road

Campbellsport, WI 53010

Tel 920-533-4258, Fax 920-533-4703



e-mail. campvista@nconnect.net

www.campvista.org






REGISTRATION FORM

Participant’s name: …………………………………………………………………………………………Born: ……… / ……… /...........

(imię i nazwisko uczestnika) data ur. (miesiąc / dzień / rok)



Parent (guardian) name: ………………………………………………. Tel: ( ……… ) ………………… Tel: ( ……… ) ………………

(imię i nazwisko jednego z rodziców / opiekuna)


Address: …………………………………………………………… City: ……………………………… State: ……… Zip: ………....

E mail: ………........…………….……....…………………………………………………………………………………………………………

Physical conditions that event organizers should be aware of: ..…..…………….…………………………………………..…………

(choroby i dolegliwości, o których organizatorzy powinni wiedzieć)

....................................................................................................................................................................................................................
...................................................................................................................................................................................................................


Medical insurance:

participant's agency name and policy#: ……………………………………………………………………….………….…………..........

(nazwa agencji ubezpieczeniowej i numer ubezpieczenia)

purchased for the time period of the event* from: ………………… to: ………………… Insurance name: …….........…..

(ubezpieczenie wykupione na czas wyjazdu) od do (nazwa ubezpieczenia)

none (bez ubezpieczenia)







Wybór turnusu i opłata:
Prosimy zaznaczyć poniżej turnus, na który mamy zarejestrować uczestnika poprzez wpisanie wielkości depozytu (minimum $50) w tabeli poniżej. Wypełnioną formę wraz z czekiem lub money order należy wysłać na adres Camp Vista (nie przyjmujemy kart kredytowych).


TURNUS / TERMIN

MIEJSCE


CENA

DEPOZYT
(wpisać sumę)

UWAGI (np. specjalne uzdolnienia, z kim w grupie, junior counselor, itp)


1 turnus, 15 - 21 czerwca 7-14 lat

Camp Vista

Sold out

- - -




2 turnus, 22 - 28 czerwca 7-14 lat

Camp Vista

$425

$

3 turnus, 29 czer. - 5 lipca 7-14 lat

Camp Vista

$425

$

4 turnus, 6 - 12 lipca 7-14 lat

Camp Vista

$425

$

5 turnus, 13 - 19 lipca 8-16 lat

Camp Vista

$425

$

6 turnus, 10 - 15 sierpnia 8-16 lat

Silver Birch

$475

$



CAMP VISTA q uczestnik $425 q junior counselor ** (od 14 do 16 lat) - $425
SILVER BIRCH q uczestnik $475
*) Ubezpieczenie na czas trwania kolonii można wykupić bezpośrednio w Travel Insured, tel.: (800) 243-3174, www.travelinsured.com, lub w innej preferowanej przez państwo agencji ubezpieczeniowej.

**) Rejestracja na tą pozycję może być tylko w Camp Vista



….............................................................................................. ……… / ……… / 2014



Parent (or guardian) signature (or participant if over 18) Date
Podpis rodzica (lub opiekuna) (lub uczestnka jezeli ma ukonczone 18 lat)
page 1 of 2



page 2

Release, Indemnification and Hold Harmless Agreement

PARTICIPANT NAME: ______________________________________ (please PRINT)

IDENTIFICATION AND ACKNOWLEDGEMENT OF RISKS
I understand, that Vista Christian Retreat (commonly known as Camp Vista) program primarily conducted in the outdoors. Camp activities such as, but not limited to, swimming, soccer, basketball, volleyball fishing, using air guns, horseback riding, rock climbing, wilderness travel, ropes course activities, lake/river activities, skiing, climbing walls, biking, backpacking, hiking, airplane rides, transportation to and from the activity site, and many others may result in property damage or fatal injury. Dangers also inherent to lakes & rivers, forces of nature such as darkness, heavy rain, lightning, strong winds, extremes of heat and cold, biting insects and animals may cause an accident or serious injury. I understand that although Camp Vista has taken reasonable precautions to provide proper equipment, suitable facilities, and trained staff, it is impossible to guarantee totally negligence free environment, absolute safety against illness, injury, or loss resulting from participation. I acknowledge the risk inherent in camp program and agree to assume that risk.

ASSUMPTION OF PERSONAL RESPONSIBILITY
I certify, that participant have no communicable diseases. I will notify Camp in writing of any medical or emotional condition that may restrict safe participation in the program. I inform, that above named participant (if under the age of 18) will not have any telecommunication devices like cell phones, 2-way radios etc. I acknowledge that participant failure to adhere to safety rules established by Camp Vista Staff may result in being asked to discontinue participation in the program. If participant is barred from further participation, or if I and/or participant voluntarily refrain from participation, or if I and/or participant leave the trip, I am responsible for all expenses incurred and I have no claim for any refunds from Camp Vista and its representatives.

AUTHORIZATION FOR MEDICAL TREATMENT
In case of an emergency, I hereby give permission to Camp Vista representatives and/or group leaders of organization who organize the event to secure medical treatment that might include hospitalization, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for participant named above. I also certify that my insurance company or myself will cover all accidental, medical and transportation costs.

CONSENT WAIVER AND RELEASE
In consideration of participating in any activities in any event organized by Camp Vista, I herby agree to release and discharge from liability Camp Vista and its owners, directors, officers, employees, agents, volunteers, participants, and all other persons or entities acting for them on behalf of myself and my children, parents, heirs, assigns, personal representative and estate. Consequently, I waive, release, and discharge any and all claims for any personal injury or damages, death, or property damage/loss, which I may have as a result of participation. I understand that Camp Vista shall not be liable for any delay or accidents of means of transportation arranged by Camp Vista, any and all acts of a third parties, or any other cases beyond their control. Camp Vista reserves the right to cancel, change, or substitute any service because of weather, safety condition of activity places/equipment, insufficient number of participants or other reasons. My registration provides Camp Vista the authorization to use photos and videos of me or registered participants for promotional purposes without further consent or compensation.

INSURANCE
I am aware, that I am responsible for paying all participant's medical expenses and related costs for any injuries that may occur during participation in the event. I agree to maintain throughout my participation, sufficient medical and accidental insurance (insurance should be valid in the State of Wisconsin). I understand that this is my sole responsibility to release all persons and entities from providing this coverage for participant.
Camp Vista strongly recommend to purchase a TRAVEL INSURANCE to protect against the risk of medical
expenses, death, travel delays, trip cancellation, any damage, loss of baggage or personal belongings, etc.



I understand and accept all terms and conditions presented to me in the English language.

(Rozumiem i akceptuję wszystkie warunki i zasady przedstawione mi w języku angielskim)






____________________________________________________________________ _____/_______/2014



signature of parent or guardian (or Participant if participant is over 18 years old)
For more information visit www.campvista.org



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