Camp Y.E.S. Registration Form 2023

1

Week of Camp* This field is required.

Ages 7-9

Ages 10-12

Ages 13-15

Ages 16-18

2

Camper's Full Name* This field is required.

First Name

Middle Name

Last Name

3

Camper's Preferred NameDoes the camper have a nickname or short form they prefer?

4

Gender* This field is required.

Male

Female

5

Age* This field is required.

6

Birth Date* This field is required.

7

Camper’s Shirt SizePlease indicate Adult or Youth as well as size.

Adult or Youth Sizing

Size (i.e., Small, Medium, Large…)

8

Address* This field is required.

Street Address

Street Address Line 2

City

Province

Postal

Country

9

Phone* This field is required.

10

Emergency Contact Name* This field is required.

11

Emergency Number* This field is required.

12

Emergency Number #2

13

Health Card Information* This field is required.Please include the Version Code and the Expiry Date

Health Card Number

Version Code

Expiry Date

14

Parent/Legal Guardian* This field is required.

15

Relation* This field is required.

16

Phone Number* This field is required.

17

Cell Phone

18

Parent /Legal Guardian 2

19

Relation 2

20

Phone 2

21

Cell Phone 2

22

Home Church* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

23

Pastor's Name* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

24

Parent's EmailBe certain to enter your email address correctly on the registration form to receive confirmation via email within 2 weeks.

25

Camper's Email

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It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration, please see the health officer at that time.

Please bring all medication in ORIGINAL CONTAINER or you will not be allowed to leave the medication/vitamins at the camp. No exceptions. All prescriptions must be in the camper's name and have the correct dosage.

Please be aware that while we try to accommodate all campers, we cannot be responsible for special dietary needs or reactions because of those needs. Please call for further information.

27

Date of last tetanus boosterIf the date is unknown or does not apply, please click NEXT.

Date

28

List all medications taken regularly* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

29

Reasons for medication* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

30

Specific allergies* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

31

Allergic to the following

Bee/Ant Stings

Penicillin

32

List specific activities to be restricted* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

33

Reason for restriction* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

34

Is there a sodium restriction for this camper?

Yes

No

35

Any dietary restrictions?* This field is required.This field is required. If it does not apply, please put "NONE" in the box. Thanks.

36

Other Information

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Camp Fees Per Family

Early Bird Rates - Register by July 1st

1st Camper	2nd Camper	3rd Camper	4th Camper
$170	$130	$110	$90

Regular Rates - Registered after July 1st

1st Camper	2nd Camper	3rd Camper	4th+ Camper
$200	$150	$125	$100

(There is NO CHARGE for a camper after the 4th camper from the same family)

38

Method of PaymentSend e-Transfers to campfees@ntbch.ca and type "Camp" in the memo. Make cheques payable to New Testament Baptist Church and write "Camp" in the memo.

e-Transfer

Cheque

Cash

39

Camper Release (List anyone, including parents, to whom your camper can be released)* This field is required.

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By putting your initials and hitting "submit", you agree that you are the parent or legal guardian of the above-named camper and are over the age of 18.

I certify that my child has my permission to attend Camp Y.E.S. 2021 and to take part in all its activities.

I do also absolve and release the camp and its administration from any liability to me or the camper arising out of accident or injury suffered during those activities.

In case of medical emergency or general medical care, I understand that every reasonable effort will be made to contact me, but if I cannot be reached, I do hereby give my permission to the physicians selected by the camp staff to hospitalize and/or give proper treatment.

I understand that the above-named camper will only be released to the names listed above, an update may be given at registration.

I authorize Harvesters Baptist Church/Harvesters Baptist Camp and/or Camp Y.E.S. to use my camper's picture, testimony, and video in any promotional material (web, print, or media)

My child may receive any e-mails from the camp to the address submitted on this form.

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SignatureCan be signed on a touch screen

Clear

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Electronic signature, please initial* This field is required.