Camper Registration Form

Camper Registration Form

For participant ages 11-18
Church Name: *
Please select the church you are attending with.
Pastor Name *

First Name Last Name
Name of Camper *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender *

Male Female
E-mail *
example@example.com
Primary Phone Number *
Alt. Phone Number (if applicable)
Date of Birth *

Month Day Year
Age *
T-Shirt Size *
First Year Attending? *

Yes No
EARLY DISMISSAL AGREEMENT

In order for your child to be released from BPYC for any reason, the section below MUST be completed. (You must list at least one person)

You are not required to list the participant's Pastor, Youth Pastor, or Head Counselor.
Name *

First Name Last Name
Relationship *
Other (please specify relationship):
Name

First Name Last Name
Relationship
Other (please specify relationship):
Name

First Name Last Name
Relationship
Other (please specify relationship):
Name

First Name Last Name
Relationship
Other (please specify relationship):
RELEASE AND EXULPATORY AGREEMENT

I/We, in consideration of my/our child's participation in Barbourville Pentecostal Youth Camp at the Appalachian Children's Home in Barbourville, KY, do for myself/ourselves assume all risks of personal injury or property damage sustained by my/our child arising out of the child's participation in BPYC activities conducted on and off the ACH campus (such as sports and recreational activities including, but not limited to, canoeing, and release, acquit and forever discharge Barbourville Pentecostal Youth Camp and Appalachian Children's Home from any and all claims, damages, actions, or causes of action, for personal injury or property damage sustained by me/us or my/our child, in any way arising out of or connected with my/our child's participation in BPYC activities conducted on and off the Appalachian Children's Home. I/We hold BPYC/ACH harmless from any and all liability resulting from any claim, demand, action or cause of action made by me/us or my/our child in connection with my/our child's participation in Barbourville Pentecostal Youth Camp activities conducted on and off the Appalachian Children's Home campus. Photos, audio and video captured by our team during BPYC are the exclusive property of BPYC and its designees and may be used in future resources, recordings, DVD, print and web media. Camp attendance is an expression of the individual release of rights for such use.

By my signing below, I acknowledge that I have ready, completely understand, and herby agree to obey the rules and regulations of participation in all Barbourville Pentecostal Youth Camp 2022 activities. I also agree to follow the leadership of the BPYC Directors, Staffs, Couselors, and ACH Staff.
Camper Signature *

Clear
Parent/Guardian Signature *

Clear
Today's Date *

Month Day Year
Confirmation 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.
All medical information will be completed on the next page.

You will be REQUIRED to submit a copy of the camper's insurance card.

Medical Registration Form
Emergency Contact Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Primary Phone Number *
Alt. Phone Number (if applicable)
-OR CALL-
Emergency Contact's Name *

First Name Last Name
Relationship *
Primary Phone Number *
Alt. Phone Number (if applicable)
MEDICAL INFORMATION
Does the camper have any known allergies? If so, please describe below: *
If no known allergies, please put N/A for Not Applicable
Does the camper have any activity restrictions? If so, please describe below: *
If no known restrictions, please put N/A for Not Applicable
Does the camper have a chronic physical condition? If so, please describe below: *
If not, please put N/A for Not Applicable
Does the camper required any special dietary needs (such as gluten-free, diabetic dietary needs, etc.)? If so, please describe below: *
If not, please put N/A for Not Applicable
Does the camper have any required present medication? If so, please describe below and the dosage required: *
If not, please put N/A for Not Applicable
If the camper has been tested or treated for any serious physical or psychological illness within the past 3 years, please list below:
In case of needed medical attention, permission is given to the Barbourville Penetcostal Youth Camp and its designee to seek appropriate medical care for the above-referenced participant.

For this purpose, the following information is given below:
Family Physician *
Phone Number *
Please enter a valid phone number.
Insurance Company *
A copy of the card is required below
Group # *
Individual # *
I, parent/guardian name* ,hereby state that the above-named BPYC participant, is in good physical condition and has no contagious or infectious disease or symptons of the same as of this date.
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Today's Date
Confirmation 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.
A copy of the insurance card for the camper is required to keep on file in case of medical emergency.

Please upload a copy of the front and back of insurance card below.

Note: if you are taking a picture of the insurance card, please make sure the picture is clear and the information on the card is easily visable.
File Upload *

Cancel of
Total price per camper is $145.00

A minimum deposit of $95.00 is due at time of registration.

(The deposit for your child should be paid by the church)
Should be Empty:

Camper Registration Form

Medical Registration Form