Living River Summer Camp Registration

Summer Camp 2023 You & Me Adult Registration
Parent/Guardian/Adult Information
Parent/Guardian Name *

First NameLast Name
Camper (s) attending You & Me with you *
Parent/Guardian Birth Date*

MonthDayYear
Gender*

MaleFemale
Parent/Guardian T-shirt Size*
PC(USA) Church*
Church, if -Not Listed-
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
E-mail*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number*

Area CodePhone Number

Camp Information
Select the camp(s) you will attend.*

You & Me (Adult) - June 23-25

Medical Information

Please answer all questions completely.
Dietary allergies/ restrictions *
Do you require an EpiPen

YesNo
Other allergies/ restrictions (bee stings etc.).*
Do you require the use of an inhaler?

YesNo
List any medical conditions of which leadership teams should be aware
Medical Insurance Company*
Contract Holder Name*
Group #*
Contract #*
Please either upload a copy of your insurance card or take a picture of the card below.
Upload a picture of your insurance card -OR-

Browse Files

Cancelof
Take a photo of the front of your card.

Payment and Consent
You may choose to either pay now via PayPal or to pay later through your church. Please make sure you have already made arrangements with your church if you choose that selection.

The Presbytery of Sheppards and Lapsley offers some scholarships toward camp registration fees (up to half the cost of camp). If you are interested in applying for a camp scholarship, please indicate that below. Then click on the link below to continue that process.
Payment Responsibility*

I understand that I am responsible for the full amount if Living River does not receive scholarship funds from the presbytery or my home church.
Presbytery of Sheppards & Lapsley Camp Scholarship

Yes, I am interested in applying for a presbytery camp scholarship.No, I will not be applying for a presbytery camp scholarship.
Payment Options*

I will pay the full amount now.Bill my church.Scholarship from Presbytery, balance will be billed later
To complete the Scholarship Application go to http://pslpcusa.org/summer-camp/ and click the Apply for Scholarship button.
Payment via PayPal
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You & Me Camp - Adult$200.00

Total $0.00
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The payment is ready! It will be completed once you submit the form.
Photos/Publicity

I understand that photos of my child or me may be used by Living River for publicity purposes in print or on social media. Names will not be printed. If I do not wish photographs of my child to be used in this capacity I will notify staff, in writing, before the beginning of the camp session.
Informed Consent and Acknowledgement

I, the undersigned, being the parent or legal guardian of the child named above permit my child to participate in all camp activities and I will hold Living River harmless in case of injury or illness. I understand that I will be notified in case of medical or surgical emergency involving my child. However, in the event that I or persons I have designated cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand Living River will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I will notify the camp director of any problems or restrictions which would affect participation in normal camp activities prior to the camp period. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. I agree to abide by the decisions of the director(s) in the case of sending the camper home due to illness or fails to abide by the camp rules.
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.
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Summer Camp 2023 You & Me Adult Registration

Camp Information

Medical Information

Payment and Consent