Camp Registration Form

Which camp are you registering for? *

Nipgen Junior Camp (ages 9-11) Nipgen Junior High Camp (Ages 12-14) Nipgen Teens in Action (Ages 15-17) Teens of Praise General Camp (7th-12th grade) WCD Kids Kamp

Camper Information

Camper's Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Camper Cell #

Camper E-Mail

example@example.com

Birth Date *

Month Day Year

Grade entering *

Age at time of camp *

Gender *

Male Female

Name of School

Are you currently part of a youth group in a CCCU church? *

Yes No

Church Name *

Youth Leader's Name

Youth Leader's Phone Number

Youth or Adult T-Shirt? *

T-Shirt Size *

Roommate Request #1

Roommate Request #2

Parent/Guardian Information

Parent/Guardian #1 *

First Name Last Name

Phone Number *

Alt Phone Number

Parent E-mail *

example@example.com

Parent/Guardian #2

First Name Last Name

Phone Number

Alt Phone Number

CAMPER AGREEMENT

If you checkmark this box, you are promising to attend all activities and services, to obey all the rules of the camp and the grounds, and to conduct yourself as a lady/gentleman at all times.

I Agree

Today's Date

Date

MEDICAL INFORMATION
The information below is necessary for the camp nurse and/or coordinators to adequately treat your child in the event of an injury or illness. All information will remain confidential.

Physician Name *

First Name Last Name

Physician Phone Number *

Insurance Company *

Write N/A if not available

Policy/ID Number *

Write N/A if not available

Is Your Child up to date on all immunizations? *

Yes No Other

Medications your child is currently taking *

Please add in scheduled times and dosage amount. All medications must be turned in to the camp nurse at check-in. Medications must be in their original container with the camper's name and the name of the medication on the bottle.

Allergies *

Is your child able to participate in strenuous activities? *

Yes No Other

Chronic or existing illnesses (mental health included) and other needed health information. *

What else shoud counselors know about your child? *

Emergency Contact #1 Name *

First Name Last Name

Relationship *

Phone Number *

Emergency Contact #2 Name *

First Name Last Name

Relationship *

Phone Number *

PARENT OR GUARDIAN RELEASE

I understand that my child is under the supervision of quality leadership while attending camp. However, I also understand that my child will be participating in activities that could cause possible injuries, such as swimming, sports, boating, tubing and construction projects. I understand that great care is taken to ensure the safety of my child but that some of the activities may be dangerous by nature. Therefore; I release the camp and its governing board(s) as liable or responsible for injuries in the event of a lawsuit. I also give permission for my child to be transported off campgrounds for participation in camp activities. Furthermore, I authorize the Camp Coordinator, Assistant Coordinator, Camp Nurse, or any other official they deem appropriate to seek any necessary examination, treatment and/or hospital care for the camper named above under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the State of Ohio. I grant permission for photographs to be taken of my child for camp directories and for publicity use.

I, as a parent or guardian, agree with the above statement. *

Yes

I, as a parent or guardian, agree to allow camp staff to take pictures of my child for social media updates & various Evangelical Christian Youth promotions. *

Yes No Other

CAMP FEE

Please share in detail the person or church that will be paying for this student's fee. *

Write N/A if payment will be made through a scholarship fund or no payment is being made due to a waived fee.

If paying for multiple retreat fees, please place each student's name here.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, 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. I ACKNOWLEDGE THAT ALL OF THE ABOVE INFORMATION IS TRUE.

Signature *

Clear

---------------- *

First Name Last Name

Do you have another camper to register? *

PLEASE MAKE PAYMENT ONLINE

OR SEND CHECKS PAYABLE TO "CCCU" WITH YOUR STUDENT'S NAME AND THE NAME OF YOUR CAMP WRITTEN ON THE MEMO LINE.

Send checks to:
CCCU ECY
1553 Lancaster Pk
Circleville, OH

Our Contact Info:

E-mail: ecy@cccuhq.org
Phone number: 740-474-8856 (office) or
419-543-3863 (cell)

ECY Youth Camps