Language
English (US)
2021 CAMP PENIEL of the ARKANSAS PRESBYTERY REGISTRATION FORM
Spring Retreat only, $15 Lunch provided, Starts at 9am & ends around 6pm
Participant’s Name:
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Age
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Date of Birth
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Month
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Day
Year
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Grade entering in the fall?
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12th Grade
11th Grade
10th Grade
9th Grade
8th Grade
7th Grade
Adult
Cell Phone Number:
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Camper
Camper Email
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example@example.com
Parent/Guardian:
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Cell Phone Number:
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Parent/Guardian
Parent/Guardian Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
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Emergency Contact Phone:
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Home Church: (If Cumberland Presbyterian just add CP at the end)
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Pastor’s Name:
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Camper Signature
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USE YOUR MOUSE TO SIGN
Clear
Parent/Guardians Signature
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USE YOUR MOUSE TO SIGN
Clear
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MEDICAL INFORMATION
Campers
Name of Insurance Co:
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Policy No:
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Physician:
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Physician Phone:
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List recent illness the camper has had:
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Date of last TETANUS BOOSTER:
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Month
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Day
Year
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Other medical information we should know:
Allergies: to medication?
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Yes
No
If yes, list name of medication.
Allergies: To Food?
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Yes
No
If yes, list food.
Allergies to environment?
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Yes
No
If yes, list?
List medications being taken:
Dosage Frequency
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RELEASE OF ALL CLAIMS
We, (I), are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in said camp, and hereby give our (my) permission to take said participant to doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and (We/I) assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we hereby assume all transportation costs.
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Yes
No
We (parents & camper) have read and understand the water slide rules [on the following page]. Please keep a copy for your information.
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Yes
No
Water Slide Rules
CAMP PENIEL WATER SLIDE RULES AND REGULATIONS • Campers under 2 ½ feet tall are not permitted to ride. • Campers over 300 pounds in weight should ride at the staff personnel’s discretion. • All riders must ride feet first either sitting or lying on their back. • ABSOLUTELY no riding on stomach or head first is permitted. • Only one rider at a time. No trains, chain of riders are permitted. • Arms and hands must remain inside the flume. No stopping or grabbing the flume handrail is permitted. • Riders must enter the slide in a sitting position. No running or diving starts are allowed from the top of the slide. ABSOLUTELY no walking or running up the slide. • Mats or inflatable tubes are not to be used on the slide. • A minimum interval of six (6) seconds must be maintained between riders. A maximum of two (2) riders will be permitted on the steps at any time. • Loitering or lingering in the run out area or in the immediate area of the slide is not permitted. • Riders must be in good health. Pregnant women or individuals with conditions are not allowed on the slide. • All riders must wear swimsuits. Either one piece or t-shirt over two piece. Cut-off jeans are not permitted. • No jewelry can be worn while riding water slide. No combs, or foreign objects are allowed in pockets or hair while riding the water slide. • No food or drinks allowed on the water slide. • Day operation only. • Warning – Failure to follow rules can result in serious injury and removal of water slide privileges.
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Do you plan to pay in person or online below? Please make checks out to "Camp Peniel Arkansas Presbytery"
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In person Check
In person Cash
Online
Please verify that you are human
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