Special Needs CHild Registration Form

Camper Eligibility
Please see the following requisites necessary to make this camp safe and enjoyable for your child. Feel free to contact us with any questions.

Physical Ability
Must be able to move from place to place without consistent assistance
Must need limited or no assistance with eating/drinking and toilet needs
Should be able to adequately communicate daily living needs and desires (verbally or non-verbally)
Medical Needs
Must have medical needs that can be met by staff trained in basic first aid
Cannot have a disease easily transmitted during regular activities
Cannot be seizure active or require frequent monitoring, care, or assistance by a trained health professional
Cannot require 1:1 supervision
Social Ability
Must be able to participate in a non-disruptive manner
Must not display harmful behavior toward self or others
Disclaimers
We cannot provide 1:1 supervision
We cannot administer any medications
We reserve the right to determine if a child’s level of care is beyond what can be provided during the camp, and therefore may request a child find another more suitable camp environment

Child Name

First Name

Last Name

Gender

Date of Birth

YYYY

Grade (2025-2026 School Year)

Primary Language

T-shirt

Parent/Guardian Name

First Name

Last Name

Best Phone # to Reach You:

(###)

###

####

Email Address

Church you attend (if applicable):

Emergency Contact Person

If different than the parent/guardian- if same please enter “Same”:

First Name

Last Name

Relation to child:

Emergency Contact Daytime Phone:

(###)

###

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Special Needs Description

Nutrition / Feeding:

My child is fully independent

My child needs special preparation of foods (ie: soft foods only, cut into small pieces, etc)

My child needs assistance opening packages

My child needs assistance with feeding / using utensils

Snacks will be provided by the parent/guardian

Other Nutrition / Feeding Comments:

Activities

My child has no physical or behavioral restrictions

My child prefers activities such as:

The following may impact my child’s behavior / participation:

ie: bright lights, hot/cold, touch, loud noises, animals, etc

The following are things that help soothe or comfort my child

ie: favorite toy, coloring, etc

My child requires additional assistance physically moving between activities. Please describe:

I would like to share the following additional information about my child:

Allergy?

Please Note: We have a volunteer medical team on site consisting of physicians and/or nursing staff. Unfortunately, we cannot provide any medications. If a parent/guardian is volunteering with their child and has an EpiPen they would like to keep with the medical team, we would be happy to hold on to it for the parent/guardian. We cannot take or administer any other medications. For children who have food allergies, we can provide the snack schedule ahead of time as requested. For days that conflict with your child’s food allergy, we request your child bring a snack from home labeled with their full name.

Symptoms:

Action Requested:

Health Release:

I understand that in the event of an accident or injury, my child will be taken to the nearest medical facility. I give my full permission for the staff of VBS or designated sponsor to secure any emergency or routine medical treatment which is deemed necessary by a licensed physician or representative of that medical facility.

First Name

Last Name

Health Release Date

YYYY

Health Insurance Provider Name

Health Insurance Group Number

Picture Release

During VBS, photos will be taken of children involved in various activities. These photos may be used on our VBS web site and/or VBS slideshow presentations. Please select one of the following:

How did you hear about AAVBS?

Prayer Requests

Please let us know if you have any prayer requests for our Prayer team to pray over during VBS:

Additional Comments

Waiver and Release of Liability and Assumption of Risk

In consideration of my child being allowed to participate in any way in any activity at the Korean United Methodist Church of Ann Arbor (“KUMCAA”), I, the legal parent and/or guardian of the child agree to the following: 1. I understand dangers may be caused by my child’s actions and the actions of others participating in activities at KUMCAA. I also acknowledge my child’s experience and capabilities and believe my child is qualified to participate in such activities. 2. I fully understand that there may be dangers associated with the activities at KUMCAA, and that there may be losses that are either not known to me or not readily foreseeable at this time. Knowing the above, I fully accept and assume all such risks and responsibility of losses, costs and damages incurred as a result of my child’s participation in all activities at KUMCAA. 3. I hereby release, discharge, covenant not to sue and agree to hold harmless KUMCAA, its respective administrators, directors, agents, officers, volunteers and employees, other participants, and if applicable, any owners and lessors of the premises of KUMCAA (each considered one of the “releasees” herein) from all liability, claims, demands, losses, or damages caused or alleged to be caused in whole or in part by the negligence of the “releasees” or otherwise, including negligent rescue operations. Furthermore, I agree that if, despite this release, I, or anyone on my behalf makes a claim against any of the “releasees” named above, I will indemnify, save and hold harmless each of the “releasees” from any litigation, expenses, attorney fees, loss, liability, damage, or cost that may incur as the result of any such claim.

I have read this agreement, fully understand and acknowledge its terms, understand that I have given up substantial rights by signing it, and have signed it freely and voluntarily without any inducement or assurance of any nature. I intend this agreement to be a complete and unconditional release of all liability to the greatest extent allowed under Michigan law and agree that if any portion of this agreement is held to be invalid under Michigan law, that all other provisions of this agreement, notwithstanding, shall continue to be in full force and effect.