Hs Br 09 Registration Forms

Second Baptist Church High School Beach Retreat June 7 – June 12, 2009

I will be attending with (circle one) Woodway Campus

West Campus

North Campus

Pearland Campus

Cypress Campus

STUDENT INFORMATION: Name _____________________________________________________________________________ _________________ (First Name) (Last Name) Address

(Middle Name)

_____________________________________________________________________________ _________________ City _____________________________________________________

St_________

Zip________________ Home Phone # ______________________________________

Birthdate

_________________________________ Student Cell # ____________________________

Cell Carrier (Sprint, Verizon, T-

Mobile, etc) ________________

High School ________________________________________

Grade (Next Year:

Fall 2009) ___________ Gender (Circle One)

Male Female

Email Address

______________________________________________ Are you a member of Second Baptist Church? Yes or No

If not,

where?_____________________ PAYMENT OPTIONS I am paying by: Cash___________ Check______(check #_______) Credit Card _______ (Please Check One) $600 – Early Bird Full Payment Special (full payment by 4/15/09) ______ Payment in full of $600 by 4/15/09 $650 – Regular Price (4/16/09 - 5/31/09) ______ $650 $675 – Late Registration (after 5/31/09) ______ $675

CREDIT CARD INFORMATION: (Circle One)

Visa

Master Card

American Express

Discover

Card Number _________________________________________________________ Expiration Date ____________________ Name as it appears on card____________________________________________

Billing Zip

Code __________________ Card Holder’s Signature _____________________ Cardholder’s Phone Number ________________________

Second Baptist Church – High School Ministry www.second.org Mailing Address Campus Contacts 6400 Woodway Dr. Woodway 713-365-2494 Pearland 713-365-3479 Houston, TX 77057 West 713-365-2432 Office Use Only: Date

Pmt

CDT #

North 713-365-6305 Cypress 713-365-3479 Amt

Bal

1. Obey Adult Leaders without question or hesitation. They are in charge of you for the week. 2. Wear your name tag at all times. 3. Your Leader must know where you are at all times. It is your responsibility to tell your Leader where you will be during free time. 4. Absolutely no one is allowed out of their condominium after the night’s curfew. The curfew is in effect until 15 minutes before morning Silent Sounds. 5. Students are not allowed onto the Phoenix balconies without the supervision of their leader. In addition, absolutely nothing is to be dropped, thrown or hung from the condominium balconies or upper level areas. Do not feed seagulls from any balcony. 6. Profanity or cursing is not allowed. 7. Do not associate with anyone who is not a part of our Beach Retreat group. 8. Swim only when and where lifeguards are on duty. The “Buddy System” is strictly enforced. Before entering the ocean, you must (1) have a buddy, (2) check in at the lifeguard station, and (3) give your name tag to a lifeguard. 9. Keep your condominium clean. No raids, rough play or pranks. You are financially responsible for any damage to property, especially to a condominium or bus. 10. The Phoenix has Quiet Hours beginning at 10:00 p.m. each evening. Please be courteous to other guests staying at the condominiums by observing this time. 11. Do not push, pull, or throw anyone into a pool. 12. You are to be on time for all activities. 13. Be positive. Cut downs, criticism, and negative comments are not allowed.

14. Wear appropriate, conservative clothing.

The following are not allowed: short shorts, tight clothing, skimpy tank tops, tube tops, halter tops or other revealing clothing. Girls must wear one-piece swimsuits (no tankinis).

15. Be extremely cautious around traffic. NO ONE is allowed to cross the highway. This includes all food and driver rest stops on the way to and back from Orange Beach as well as while we are in Orange Beach itself. 16. Guys may not go into girls’ condos and girls may not go into guys’ condos unless your Adult Leader is present, and it is a planned and organized activity. 17. Never go anywhere by yourself. You will be allowed to visit shops and stores near the condominiums during free time, but you must be in groups of at least three. Shuttle busses will be provided. 18. You are not allowed to bring or purchase any of the following: alcoholic beverages, tobacco products, firearms, knives, drugs, fireworks, electronic equipment (televisions, video games, IPods, cell phones, etc) balloons, balloon launchers, or inappropriate T-shirts. While on the retreat, you may not participate in any of the following: tattooing, haircuts, hair coloring, or ear/body piercing. Your Adult Leader will inspect your luggage when we arrive at the Phoenix Condominiums. 19. During your free time, you are not to be in any condo including your own, for more than 10 minutes, unless your Adult Leader is present. 20. Any student who sets off a fire alarm as a prank will be turned over to the police department. Upon release, the student will be sent home immediately.

STUDENTS WHO CAUSE PROBLEMS ON THE RETREAT WILL LOSE FREE TIME PRIVILEGES OR BE SENT HOME AT PARENTS’ EXPENSE. Student’s Signature____________________________________________________________________ _________ Parent’s Signature____________________________________________________________________ ___________

Your Name:__________________________________________________ Your Cell Phone # ____________________________________________ Your E-Mail Address _____________________________________________ High School _______________________ Grade (Next Year: Fall 2009) ____ List two friends with whom you want to room at Beach Retreat 2009: 1. ______________________

and

Attach Recent Photo Your Beach Retreat application is not complete unless a picture is attached.

2. _____________________

1. What are some of your hobbies or talents? 2. What would you say is your most attractive quality and your least attractive quality? 3. On a scale of 1 to 10 (one being absolutely lousy and 10 being unbelievably incredible), how would you rate your life right now? Why? 4. In 20 words or less describe your relationship with God right now. 5. When God looks at you what do you think He sees? 6. Finish this sentence, “The thing that people most misunderstand about me…” 7. The best and worst things about your parents are… 8. What does it mean to be “a Christian”? 9. Who has helped you the most in your relationship with God? 10. Have you ever trusted in Jesus Christ to be your Savior? When was that? 11. Is your family involved in church? Do they support you being involved? 12. Have you ever been baptized? When and where? 13. Is there anything you are struggling with right now that you would like to talk with someone about this week?

SECOND BAPTIST CHURCH STUDENT MINISTRY Registration and Medical Information Parental Permission and Release (Please Print)

Student’s Name_________________________

Grade (Next Year: Fall 2009) ________

Date of Birth___________________________

School______________________________

Primary Address________________________ __________________________ Father’s Name__________________________

Mother’s Name_______________________

Home Telephone________________________ Business Telephone______________________ Cellular Telephone_______________________

Home Telephone______________________ Business Telephone___________________ Cellular Telephone____________________

Emergency Contacts (Other than Parents) Contact #1

Contact #2

Name_________________________________ Relationship to Child_____________________ Home Telephone________________________ Business Telephone______________________ Cellular Telephone_______________________

Name_______________________________ Relationship to Child__________________ Home Telephone_____________________ Business Telephone___________________ Cellular Telephone____________________

Medical History and Current Information Current Medical Problems_________________ ______________________________________ ______________________________________ ______________________________________

Drug Allergies________________________ Food Allergies________________________ Insect Allergies_______________________

Current Medications Dosage ________________________________ _________ ______________________________ ________________________________ _________ ______________________________ ________________________________ _________ ______________________________ ________________________________ _________ ______________________________

Schedule

Parent/Legal Guardian’s Signature(s) _________________ __________________________

SECOND BAPTIST CHURCH STUDENT MINISTRY Registration and Medical Information Parental Permission and Release Please indicate if your child has ever had any of the following. If you mark yes to any condition, please explain in detail below including date of diagnosis and current treatment. Yes No Yes No Diabetes/Hypoglycemia _____ _____ Asthma _____ _____ ADD/ADHD _____ _____

Depression/Metal Health Seizures Migraines

_____ _____ _____ _____ _____ _____

Explain:_______________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ __ Any Special Conditions not listed above:____________________________________________ _____________________________________________________________________________ _ Medical Release I/We, ______________________________, the parent(s) of __________________________ do hereby give over and release unto the staff and chaperones of Second Baptist Church of Houston all authority and responsibility to authorize any and all medical treatment necessary for the protection of the health and well-being of my aforementioned child. This authorization shall authorize any and all medical treatment by licensed medical personnel, pursuant to the express authorization, whether written or oral of the above mentioned representatives. This authorization shall be effective on June 7, 2009 through June 12, 2009, inclusive or until it is expressly revoked. I hereby grant permission for the Second Baptist Nurse or trained designate to administer over-the-counter medications, including but not limited to: Tylenol, Ibuprofen, Pseudophed, Claritin, Tums, Benadryl, Anti-Itch Cream, Delsym, Visine eye drops. I hereby release Second Baptist Church, its staff, chaperones, and volunteers, from any and all claims and liabilities of whatsoever nature, both individually and collectively, that may arise from my child’s participation in this event. I/We understand that I/we will be financially responsible for any medical costs incurred in the emergency treatment and/or transportation of my child.

Transportation and Property I/We further understand that my child will be transported in equipment owned, leased, or rented by Second Baptist Church. I/We understand that I/we are financially responsible for any damage caused by or in part by my child. This includes all private and public property.

Promotional Release Second Baptist Church has my permission to use any photographs/video of the above named child for brochures, videos, advertising, web page, other promotional items. I/we further understand that these photos/videos will only be used for SBC promotional purposes. Yes or No (Circle One) I/We acknowledge that I/we have read and understand all aspects of both sides of this document. I/We agree that copied representations of our signatures should be accepted as binding. This form must be signed in the presence of a witness. Both parent signatures are preferable, but only one parent signature is required.

A copy of your Health Insurance Card must accompany form for your registration to be complete. Parent/Legal Guardian’s Signature(s) ________________

_____________________

Date:_____________________