Junior Camp Registration and Release

Name of Camper *

First Name Last Name

Birth Date of Camper *

Birth Date

Name of Church Attending Camp *

Church Name

Pastor *

Pastor Name

Gender *

Gender

Grade (For 2021-2022 School Year) *

Grade Level

Camper Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code

Camper Primary Phone Number *

Area Code Phone Number

Parent/Camper Email (For Updates) *

Confirmation Email Email must be confirmed. If no email is available, use none@none.com.

May we provide Camp updates via email listed above?

Yes. No. I will work with my designated leader to receive necessary information in printed format.

Camper's Preferred T-Shirt Size (For All Campers Who Register Up To 2 Weeks Prior To Camp)

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL Adult 2XL

The cost of camp is $150 per person. How will this be paid? (If you have questions regarding this fee, talk to your camp organizer.) *

Out of Pocket - Check/Cash Out of Pocket - PayPal/Card Partial Scholarship Full Scholarship

NOTE: Unless a scholarship has been selected above, please make payment within 5 days of registering, no later than the day prior to Camp. Payment instructions will be provided through your camp organizer. Checks can be made to Faith Temple Church with "Camp Registration" in memo. Card payments are accepted through PayPal (link on church site or HERE), selecting "Camp Registration" in the dropdown. Participating churches may offer additional payment options.

Parent 1 Name *

First Name Last Name

Parent 1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent 1 Email

Parent 1 Main Phone *

Area Code Phone Number

Parent 1 Cell Phone

Area Code Phone Number

Parent 1 Work Phone

Area Code Phone Number

Parent 2 Name

First Name Last Name

Parent 2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent 2 Email

Parent 2 Main Phone

Area Code Phone Number

Parent 2 Cell Phone

Area Code Phone Number

Parent 2 Work Phone

Area Code Phone Number

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

A hospital and clinic are within five miles of the campground. Registration fees include accident insurance for all campers. Water activities are supervised by adults and qualified water safety personnel.

List any Camper allergies and supporting detail that the staff needs to be aware of. *

List any Camper medical conditions that the staff needs to be aware of. *

For campers covered by insurance, we ask that basic information be provided in the event of an emergency. Please fill out the company and policy information below and/or provide insurance card photo (take picture via phone or upload via desktop).

Insurance Company

Insurance Policy #

OPTIONAL: Take photo of Insurance Card (Mobile Phone).

OPTIONAL: Upload photo of Insurance Card (desktop).

Camper's Special Dietary Needs

Camper's Family Physician

Camper's Physician Phone #

List any physical activities which need to be monitored or avoided for the Camper.

List any prescription or non-prescription medications Camper may bring to camp.

Please make arrangements with designated group leader prior to departure to secure any medication needed during camp.

Do you give permission for Camper to take over-the-counter medications if necessary? (i.e. for headaches, upset stomach, cramps) *

Yes No N/A - Adult 18+

Is there anything else the staff needs to know regarding the Camper's health, possible behaviors, and or major life events that may impact their experience?

Details will be used only to ensure the safety and wellbeing of each camper. Please discuss specific concerns with designated group leader.

INFORMED CONSENT AND ACKNOWLEDGEMENT
The Camper has permission to participate in all Church camp activities except limitations noted above. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Church and all its respective officers, agents, and representatives from any and all liability for injuries to Camper arising out of traveling to, participating in, or returning from selected camp sessions.

EMERGENCIES AND INJURIES
In case of emergency, I hereby give permission to the doctor selected by Church staff to secure proper treatment (including hospitalization and surgery) for the Camper. In case of injury to Camper, I hereby waive all claims against the Church, all participants and counselors, and owners and lessors of premises used to conduct the event.

I realize that Church staff will attempt to contact parent(s) and/or emergency contact listed above if an accident or illness occurs requiring medical treatment by a physician, and best efforts will be made to do so prior to seeking such treatment. I understand that camp insurance is a supplemental policy only and that my insurance (as applicable) will be considered primary coverage should a medical situation arise. If deemed necessary, I give permission for the camp director or designated staff person to provide treatment to the Camper from the camp's non-prescription First Aid supplies.

PHOTOS & VIDEOS
I give permission to use any photos or videos of the Camper in publications, websites, and other camp promotions.

DISCIPLINE
I understand that if the Camper is having disipline problems that jeopardize the safety of others, I will be contacted and the Camper may be required to return home early.

COVID-19
I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that the Camper may be unintentionally exposed while attending camp. I understand that the Camper must be free from COVID-19 symptoms and other known communicable diseases in order to participate in Camp.

I have fully read this form in whole and have stated everything to be accurate to the best of my knowledge.

Electronic Signature *

BY ACKNOWLEDGING AND SIGNING ABOVE, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. Clear

Today's Date *

Month Day Year

Junior Camp 2021

Parent/Guardian Information

Non-Parent Emergency Contact (During Time At Camp)

Health and Safety Information

CAMPER CONSENT & RELEASE