Camper Registration Form 2023 - July 31

Southwest Reformed Youth Camp - July 31 - August 3, 2023
We are excited about your interest in the 2023 Youth Camp! Please take a moment to complete this registration form.

This completed and signed Camper Registration and Participation Agreement constitutes a request on behalf of the Camper named below to participate in a Youth Camp (“Camp”) sponsored by Grace Presbyterian Church and scheduled to take place at Palomar Christian Conference Center in Palomar Mountain, CA (“Palomar”), from Monday, July 31 through Thursday, August 3 of 2023.
Camper Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade for Fall 2023*
Sex:*

MaleFemale
Names of Parents/Guardians*
Parent E-mail*
example@example.com
Home Church, City, & Denomination*
Church Phone Number*
Pastor's Name*
Are you a member?*

YesNo
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone or Parent's Cell Phone*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number:*
Please enter a valid phone number.
Emergency Contact Email:*
example@example.com
Relation to Camper:*
At the conclusion of Camp and/or in the event of an emergency, any of the following adults at least 18 years of age (in addition to the Emergency Contact named above) are authorized to pick up the above-named Camper:
Authorized Pick-Up #1*
Authorized Pick-Up #2*
Medical Release Agreement and Parent/Guardian Consent

The undersigned represents and acknowledges that the above-named Camper carries and is covered by his/her own medical insurance. Palomar and Camp staff are safety conscious and follow appropriate safety procedures, and in the event of injury or illness EVERY EFFORT WILL BE MADE TO CONTACT THE EMERGENCY CONTACT NAMED ABOVE. The undersigned authorizes Camp staff to administer first aid, and/or consent to medical treatment where, in the judgment of Camp staff, this becomes necessary.

The undersigned further authorizes Camp staff to receive physical custody of the Camper upon completion of any treatment. The health information on this form will only be shared, as needed, with Palomar group leaders, Camp staff, and medical professionals to safeguard and support the Camper. This information will not be publicly disseminated or released to any outside organization.
Camper’s Health History

The undersigned Parent/Guardian represents that the above-named Camper is capable of participating in Camp activities and will not participate in any activities prohibited by said Parent/Guardian.
Describe any relevant health issues:
List any allergies:
List any other conditions, activity restrictions, or special-care needs:
Provide the name and dosage of any medications that the Camper is required to take. Please note: Camp leaders must be informed of ANY PRESCRIPTION MEDICATIONS BROUGHT BY YOUTH, with clear directions as to proper use and dosage. If medication is “as needed,” each Camper must understand the symptoms of his/her condition(s) and know when to ask Camp staff for help.
There will be a well-stocked first aid kit on hand for all activities. The following is a comprehensive list of the medications, ointments, and treatments available at Camp as needs arise. Please check each treatment that Camp staff and leaders are NOT authorized to administer to this Camper. Where considered necessary in the judgment of Camp staff, all other treatments below will be administered according to manufacturer’s packaging. Any medication NOT authorized will NOT be administered under any circumstances.

BenadrylAcetaminophenIbuprofinEye DropsHydrogen PeroxideAntibiotic OintmentCough DropsAntacid TabletsLeperamide (Maalox/Imodium)Insect Sting ReliefCalamine LotionInsect Repellant
Code of Conduct

It is expected that all Campers will conduct themselves in a Christian manner at all times during the Camp. Where, in the judgment of Camp staff, and after being warned against such, a Camper defiantly continues in inappropriate conduct or language, presents significant behavioral problems, or engages in particularly egregious actions that could endanger himself or others, the Camper may be dismissed from Camp. In such cases, a Parent/Guardian will be requested to pick up the Camper within 6 hours, and no portion of the Camp fees will be refunded.

Parent/Guardian Consent and Release of Liability

Execution of this Agreement represents an assumption of risk by the Camper and a waiver of liability for any injuries incurred by the Camper from participation in activities at the Camp, and explicit indemnification for liabilities of every kind against Grace Presbyterian Church, Palomar, Camp staff, or any other person or organization connected with the supervision or operation of the Camp.

Grace Presbyterian Church retains the right and permission to publish photographs taken during Youth Camp for use in electronic or print publications.

The undersigned Parent/Guardian or adult Camper hereby acknowledges and represents that he/she is at least 18 years of age, has read this entire document, understands its terms and provisions, recognizes that this is a binding agreement, and is signing electronically below voluntarily and in full cognizance of these facts.
Name of Parent/Guardian (or Camper if over 18):
Signature*

Clear
After hitting the "Register" button below, you will be taken to a payment page. Please select the Youth Camp payment option for One Camper or Two+ Campers depending on the total number of children you will be registering.
Should be Empty:

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Southwest Reformed Youth Camp - July 31 - August 3, 2023