Summer 2023 Registration

Please list ALL medications, including over-the-counter or nonprescription drugs, taken routinely. Bring enough medication to last the entire time at camp. Medications must be kept in the original packaging/bottle that identifies the prescribing physician (if a prescription), the name of the medication, the dosage and frequency. We are not allowed by law to dispense any prescription drugs without this identification.

If your attendee takes more than 5 medications, please bring a complete list with the name of medication, time taken, amount/dose, oral or topical.

NOTE: Health Care staff dispense medication to program sites at Breakfast, Lunch, Supper & Bedtime. Please advise the camper of
these times. If there is a major health issue requiring dispensing medication at any other time, please contact the Program Specialist (785-375-0137) a week before the camper is due at camp.

IMPORTANT: THIS FORM MUST BE COMPLETED AND SIGNED BY PARENT/CUSTODIAL GUARDIAN FOR ATTENDANCE.

This health history is correct so far as I know, and the person described has permission to engage in all prescribed camp
activities except as noted. AUTHORIZATION FOR TREATMENT: I hereby give permission to the medical personnel selected by
Camp Tomah Shinga to order x-rays, routine tests, treatment and necessary transportation for attendee/camper. In the event
I cannot be reached in an emergency, I hereby give permission to the physician selected by Camp Tomah Shinga to secure
and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for offsite trips.

I (parent/guardian) give permission for Camp Tomah Shinga to administer over-the-counter medications and provide first aid if
the Health Care staff deems necessary. I understand the Camp Tomah Shinga Health Care staff will administer medications per
instructions and protocols in the Camp Tomah Shinga Health Care Plan, which is approved by a physician, that treatments and medications will be administered according to the directions on the bottle/packages unless a physician directs otherwise, and that the health history form will be reviewed for allergies and parental recommendations prior to that administration.

All participants will follow all safety procedures and guidelines as instructed by the facilitators. Participating in this program may involve bending, twisting, lifting, running, jumping, climbing, increased heart or breath rates and physical contact with others. Unexpected strains or jolts to your body can occur.

I understand that this activity could cause serious illness and/or injury, and I assume all risks for any such illness and/or injury. I realize that the Challenge Course/Climbing program might jeopardize my health if I have a history of heart problems or high blood pressure, am pregnant, recovering from broken bones, dislocated joints, sprains, strains, back or neck injuries, have an enlarged organ, am a transplant recipient, or have Down Syndrome. Participants with any of these or other physical concerns should talk with the staff prior to the start of the Challenge Course event.

In the event of illness or injury, I do hereby consent to whatever medical treatment and hospital care may be considered necessary in the best judgment of the attending physician, surgeon, or dentist performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

As a condition of my participation in this activity, I agree to waive all claims against Lutheran Outdoor Ministries Association of Kansas/Nebraska Lutheran Outdoor Ministries and to hold its employees harmless from any and all liability or claims because of any death, bodily injury, personal injury, or illness that may arise out of or in any way be connected with the above-described activity. This waiver shall not apply to any occurrence that may arise solely out of the negligence of its employees or agents.

I am aware that I might be photographed and/or videotaped during my participation and authorize such photographs and/or videotapes to be used in training or promotional materials at any point in the future. I understand that my name will not be used and/or published in any way, and that I will not receive compensation for the use of such photographs and/or videotapes.

By signing below, I am agreeing that I have carefully read and agree to all of the sections above.

*Family camp does not qualify.

Regular (early bird)
Family Camp: $440
Explorers: $310
Pathfinders: $475
Trailblazers: $475
Pioneers: $475

Special (early bird)
Confirmation Camp: $475
Fishing Camp: $475
Night Camp: $475
FORGED Running Camp: $415