
Jason & LaCinda Whittington
7217 Glenn Hills Drive
Sherwood AR 72120
870-219-5636
lacinda.whittington@hacogop.org
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DIABETES
ASTHMA
CONVULSIONS
SLEEP WALKING
TUBERCULOSIS
HEART PROBLEMS
IVY, OAK, SUMAC POISONING
FAINTING
KIDNEY PROBLEMS
BED WETTING
ADD/ADHD
OTHER: LIST BELOW
NONE
PENNICILLIN
MILK/DAIRY
FOOD: LIST BELOW
OTHER: LIST BELOW
NO ALLERGIES

COVID STATEMENT & WAIVER
CAMP KAHOKA HAS PUT IN PLACE PREVENTATIVE MEASURES TO REDUCE THE SPREAD OF COVID-19; HOWEVER, CAMP KAHOKA CANNOT GUARANTEE THAT YOU OR YOUR CHILD(REN) WILL NOT BECOME INFECTED WITH COVID-19. FURTHER, ATTENDING CAMP KAHOKA COULD INCREASE YOUR RISK OF CONTRACTING COVID-19. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THE CONTAGIOUS NATURE OF COVID-19 AND VOLUNTARILY ASSUME THE RISK THAT MY CHILD(REN)/I MAY BE EXPOSED TO OR INFECTED BY COVID-19 BY ATTENDING CAMP KAHOKA AND THAT SUCH EXPOSURE OR INFECTION MAY RESULT IN PERSONAL INJURY, ILLNESS, PERMANENT DISABILITY, AND DEATH. I UNDERSTAND THAT THE RISK OF BECOMING EXPOSED TO OR INFECTED BY COVID-19 AT CAMP KAHOKA MAY RESULT FROM THE ACTIONS, OMISSIONS, OR NEGLIGENCE OF MYSELF AND OTHERS, INCLUDING, BUT NOT LIMITED TO, CAMP KAHOKA EMPLOYEES, VOLUNTEERS, AND PROGRAM PARTICIPANTS AND THEIR FAMILIES.
I UNDERSTAND THAT MY CHILD(REN)/ I MUST BE FREE FROM COVID-19 SYMPTOMS, AND SHOULD SYMPTOMS DEVELOP WHILE IN THE CARE OF CAMP KAHOKA, MY CHILD(REN)/ I WILL BE SEPARATED FROM THE REST OF THE CAMP PARTICIPANTS/STAFF. I WILL BE CONTACTED, AND MY CHILD MUST BE PICKED UP WITHIN THREE HOURS OF MY BEING NOTIFIED. I FURTHER VOLUNTARILY AGREE THAT CAMP KAHOKA MAY MONITOR MYSELF OR MY CHILD(REN) FOR SYMPTOMS OF COVID-19 (INCLUDING, BUT NOT LIMITED TO, FEVER OF 100.4 DEGREES FAHRENHEIT OR HIGHER, SHORTNESS OF BREATH, CHILD, DRY COUGH, SORE THROAT, AND MUSCLE ACHES)
I WILL IMMEDIATELY NOTIFY CAMP MANAGEMENT IF I BECOME AWARE OF ANY PERSON WITH WHOM MY CHILD OR I HAVE HAD CONTACT EXHIBITS ANY SYMPTOMS OF COVID-19, IS ADVISED TO SELF-ISOLATE, QUARANTINE, OR HAS TESTED POSITIVE FOR COVID-19.
I VOLUNTARILY AGREE TO ASSUME ALL OF THE FOREGOING RISKS AND ACCEPT SOLE RESPONSIBILITY FOR ANY INJURY TO MY CHILD(REN) OR MYSELF (INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY, DISABILITY, AND DEATH, ILLNESS, DAMAGE, LOSS, CLAIM, LIABILITY, OR EXPENSE, OF ANY KIND, THAT I MAY EXPERIENCE OR INCUR IN CONNECTION WITH MY ATTENDANCE AT CAMP OR PARTICIPATION IN CAMP PROGRAMMING ("CLAIMS”) ON MY BEHALF, I HEREBY RELEASE, COVENANT NOT TO SUE, DISCHARGE, AND FOREVER HOLD HARMLESS CAMP KAHOKA, CHURCH OF GOD OF PROPHECY, ITS BOARD, DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, CONTRACTORS AND AFFILIATES AS WELL AS THE RELEASE PARTIES AND REPRESENTATIVES OF AND FROM THE CLAIMS, INCLUDING ALL LIABILITIES, CLAIMS, ACTIONS, DAMAGES, COSTS OR EXPENSES OF ANY KIND ARISING OUT OF OR RELATING THERETO. I UNDERSTAND AND AGREE THAT THIS RELEASE INCLUDES ANY CLAIMS BASED ON THE ACTIONS, OMISSIONS, OR NEGLIGENCE OF THE CAMP, ITS EMPLOYEES, AGENTS, AND REPRESENTATIVES, WHETHER A COVID-19 INFECTION OCCURS BEFORE, DURING OR AFTER PARTICIPATION IN ANY CAMP PROGRAM.

ALCOHOL
DRUGS
TOBACCO
VAPES,
JUULS ETC.
GUNS
KNIVES
WEAPONS OF ANY KIND
- TOILETIRES
- TOWELS
- WASHCLOTHS
- CASUAL CLOTHES
- CLOSED-TOE SHOES
- TWIN-SIZED BEDDING (SHEET, BLANKET, PILLOW, SLEEPING BAG)
- WATER CLOTHES
- BIBLE, PEN &PAPER
- DONOT BRING:VALUABLES; JEWELRY, LARGE AMOUNTS OF CASH, COMPUTER, VIDEO GAMES, ANY ELECTRONICS
DRESS CODE: THE INTENT OF A DRESS CODE IS TO PROVIDE AN EQUITABLE DRESS CODE FOR ALLCAMPERS THAT ENCOURAGES MODESTY.
· APPAREL MAY NOT EXPOSE THE MIDRIFF, BE TIGHT FITTING, OR HAVE WRITING ON THE BACK OF PANTS OR SHORTS.
· APPAREL THAT SYMBOLIZES TOBACCO, ALCOHOL, DRUGS, VIOLENCE, SEX, OR INAPPROPRIATE LANGUAGE IS NOT ALLOWED
· DRESSES & SHORTS SHOULD BE MODEST IN LENGTH (MUST BE FINGERTIP LENGTH; SHOWING PAST THE ENDS OF THE FINGERS.)
· COVER SHORTS UNDER DRESSES SHOULD BE CONSIDERED FOR YOUNGER CAMPERS.
· LEGGINGS SHOULD BE WORN WITH A SHIRT THAT FALLS BELOW THE HIPS.
· STRAPLESS, SPAGHETTI STRAPS, TANK TOPS, OR T-SHIRTS CUT OPEN ON THE SIDES ARE NOT ALLOWED.
· SHOES MUST BE WORN AT ALL TIMES WHEN OUTSIDE THE CABIN.
· SWIMSUITS MAY BE WORN UNDER CLOTHES WHEN PARTICIPATING IN WATER DAY.
· CAMPING MINISTRY ADMINISTRATION RESERVES THE RIGHT TO CORRECT CLOTHING CONCERNS.
STATEMENT OF UNDERSTANDING, CONSENT, AND RELEASE
I UNDERSTAND THAT CAMP KAHOKA IS A MINISTRY OF THE CHURCH OF GOD OF PROPHECY AND CONSEQUENTLY ALL ACTIONS, CONDUCT, AND POLICIES WILL BE CONSISTENT WITH THE CHURCH’S STATEMENT OF DOCTRINE AND BELIEFS. IN CASE OF AN EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME (PARENT OR GUARDIAN). IN THE EVENT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO CAMP KAHOKA ADMINISTRATION, DIRECTORS, STAFF AND PHYSICIANS SELECTED BY THE CAMP TO SECURE PROPER TREATMENT FOR, TO ADMINISTER "OVER-THE-COUNTER” (OTC) OR PRESCRIPTION MEDICATIONS, TO HOSPITALIZE, ORDER INJECTION, ANESTHESIA, AND /OR SURGERY FOR THE CAMPER.
I UNDERSTAND THAT MY INSURANCE HAS THE PRIMARY RESPONSIBILITY OF PAYMENT SHOULD MY CHILD/I NEED TREATMENT. THE CAMP INSURANCE IS SECONDARY. I UNDERSTAND THAT ALL MEDCIATIONS, INCLUDING OTC MUST BE ADMINISTERED BY THE CAMP MEDICAL PERSONNEL AND THAT MEDICATIONS WILL BE COLLECTED AT THE TIME OF REGISTRATION.
I CERTIFY THAT ALL INFORMATION PROVIDE ON THIS APPLICATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
I HAVE READ AND UNDERSTAND THE CAMP RULES AND REGULATIONS AND ALSO UNDERSTAND THAT BY SIGNING THIS APPLICATION I/REGISTRANT AM AGREEING TO ABIDE BY THOSE RULES. I UNDERSTAND THAT FAILURE TO DO SO COULD RESULT IN DISMISSAL FROM CAMP. ANY CONDUCT INCOMPATIBLE, INCONSISTENT, OR CONFLICTING WITH THE MISSION OF CAMP KAHOKA AS A CHRISTIAN CAMP WILL CONSTITUTE REASON OR CAUSE FOR DISMISSAL FROM CAMP AND/OR THE DECISION TO REFUSE ACCEPTANCE TO FUTURE CAMPS. I ALSO AGREE THAT THE CHURCH OF GOD OF PROPHECY (LOCAL, REGIONAL, AND INTERNATIONAL OFFICES) AND ITS OFFICERS, SERVANTS, AND STAFF SHALL NOT BE HELD RESPONSIBLE FOR DAMAGES FOR ANY ACCIDENT OR SICKENESS INVOLVING MY CHILD.
