NCR Camper Application 2023

2023 - NCR CAMPER Registration

NCR P.O. Box 7460, Bismarck, ND 58507

Questions regarding completion of this form may be addressed in writing to the Youth Director, Erich D. Lacks, at pastor@lighthousechurchdickinson.com (423) 284-5552. Business Hours M-TH 9:00am--3:00pm

*Please note: The NCR Youth & Discipleship Department perfers the online applications and submissions.

Payments will be accepted in the office or ONLINE. Preferably online.

Which camp are you attending? Grade is based on what grade you are entering this fall. Montana Camp is June 26-30, 2023 and Dakotas Camp is August 7-11, 2023.

Dakota Junior Camp (1st-5th Grade) $215Dakota Senior Camp (6-12 Grade) $215Montana Junior Camp (1st-5th Grade) $140. Walk on rate will be $150Montana Senior Camp (6-12 Grade) $140. Walk on rate will be $150

**6th Graders or 11-12 year olds (some 6th graders are as young as 11) will have the option to stay in Junior Camp. ***Parent/Guardian, If you have a 11-12 year old, in 6th grade, do you want your child to attend Junior or Teen Camp?*

JuniorTeen

I CERTIFY that I am the parent or legal guardian for the student listed below. I am present and actively engaged in the completion of this form.

Signature

Student's Name:

Please type your child's name in the box above.

Name

Address

Street Address

City

State Province Region

Postal Zip Code

Country

Parent/Guardian Name

Additional Parent/Guardian Name

Parent Email (Note: Confirmation is sent via email. Must have a valid email address. Please double check the spelling of your email address. Your confirmation along with important updates will be mostly communicated through email)

Email*

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.

List all pre-existing medical conditions and medications you must take. If none, LIST N/A. There MUST be a pharmacy label and directions on the prescribed medication. When you arrive at Camp, all medications will be turned in to the Nurse.*

Medical Insurance Company: if you do not have insurance, please list N/A

Insured id/Mbr#: If no insurance, type N/A .

Policy Holder DOB: if no insurance, type 10/00/0000

File Upload

Please Note: Due to the nature of our camp structure, we will do our best to accommodate specific menus regarding food allergies. Please list any and all allergies we need to be aware of. *

What church does the applicant attend?

Church Name:

ROOMMATES: YOU WILL AUTOMATICALLY BE PLACED WITH OTHER STUDENTS FROM YOUR LOCAL CHURCH.

If there is an additional student that you prefer to room with that does not attend your church, please list their name below.

Roommate Preference

Pastor Name: For Pastoral Endorsement/Recommendation. Your Pastor MUST endorse and recommend you. Your application is incomplete without their endorsement.

Pastor's Name*

I have had sufficient opportunity to read this entire document and its terms and conditions. I have read and understood it and agree to be bound by its terms.

In Consideration of the services of North Central Region (NCR) Executive Office, their agents. owners, officers, volunteers. participants. employees. and all other persons or entities acting in any capacity on their behalf thereinafter collectively referred to as hereby agree to release, indemnify and discharge NCR on behalf of my spouse, my children, my parents. my heirs, assigns, personal representative, and estate as follows:

1.I acknowledge that outdoor adventure based activities and physical activities entail known and snanticipated risks that could result in physical of emotional injury, paralysis, death of damage to myself, damage to property, or damage to third parties. I understand that such risks simply cannot be eliminated withost jeopardizing the essential qualities of the activity.

The risks include, among other things This program is based on the "challenge by choice" principle. At any time you and/or your group are free to withdraw from participation in all other physical activities and its potential for slips and falls and falling rope burns: accidental drowning, pinches, scrapes, twists and joits that could result in scratches, bruising, sprains, lacerations, fractures, concussions, or stings, allergies, and associated diseases.

Furthermore. NCR and Camp employees, volunteers, and representatives have difficult jobs to perfore. They seek safety, but they are not infallible. They might be unaware of participant's fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions. and the equipment being used might malfunction.

2. I expressly agree to assume all of the risks existing in this activity. My participation in this activity is purely voluntary. and elect to participate fully aware of the risks

3. I hereby voluntarily release. forever discharge. and agree to indemeify and hold harmless NCR from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of NCR's equipment or facilities, including any such claims which allege segligent acts or omissions of the NCR.

4. Should NCR or any one acting on their behalf be required to incur legal fees and costs to enforce this agreement. I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have insurance to cover any injury or damage may cause or suffer while participating, or else agree to bear the costs of such injury or damage myself. further certify that assume the risk of any medical or physical conditions I may have.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by court of law to have walved my right to maintain a Lawsult against the NCR on the basis of any claim from which have released from herein.

By submitting as application to the camp, each camper agrees

1. He/she will abide by all rules and operations of the camp.

2. The camp is private operated camp and is not public accommodation

3. He/she will abide by all the neachings/tenets/practices of the Church of God.

4. Any violation of rules/regulations may result in the dismissal of the Camper from the camp, at the camper's expense, including transportation home.

5. His/her belongings, sultcases, backpacks, and all possessions, may be searched at any time by the camp administration.

6. Camp administration reserves the right to dismiss any camper for any reason, all in the sole discretion of the camp administration

I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

Thereby give my child permission to attend and participate in the NCR Youth Camp. I hereby waive, release, and discharge any and all claims, demands, and cases of action against Camp Officials, the Church of God in the NCR, and the International Offices of the Church of God, their agents, employees, and participants arising from any damages, property loss, or injury my child sustains at the NCR Youth Camp. I further consent to allow Camp Officials to seek and obtain emergency medical or surgical treatment for my child should my child need medical treatment. I further grant permission for my child to appear in Camp Videos and any promotional videos or photography. I fully understand that my family's insurance is the primary carrier for all accidents incurred at camp and the camp's insurance is the secondary carrier.

I agree to the terms and conditions in the terms and conditions clause above.

Signature

In consideration of by the NCR to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless the NCR from any and all claims which are brought by, or on behalf of my MINOR; and which are in any way connected with such use or participation by MINOR, being permitted.

PLEASE TYPE THE MINOR'S NAME IN THE BOX ABOVE.

***Parent/Guardian Signature: Your signature represents permission AND verifies that you are the student's parent/legal guardian or application is null and void.***

Date of application being filled out:

Date

Early Bird--ends April 27, 2023 for Montana Camp and June 9, 2023 for Dakota Camp:

There is a $50 non-refundable deposit. Deposits paid by the early bird deadline will lock you in at the early bird rate.

Montana early bird price is $130; after 4/27, the rate is $140, and walk-ons will be $150

Dakota early bird price is $195; after 6/9 the rate is $205, and walk-ons will be $215

Whatever balance remains is to be paid on or before the first day of camp.

The Camp dates and locations are as follows:

Montana Camp, June 26-30, 2023 at the Four Winds Ministry Center in Big Timber, MT

Dakotas Camp, August, 7-11, 2023 at Crystal Springs Camp in Medina, ND

1. EARLY BIRD REGISTRATION FEE (at least a $50 deposit paid): Early bird price is $130 for Montana and $195 for Dakotas

DEPOSIT of $50.00 with the remaining balance due by the first day of Camp.

2. REGULAR RATE REGISTRATION FEE (After 4/27-Montana or after 6/9-Dakota up to Camp start date) $140 for Montana and $205 for Dakotas.

3. WALK-ONS: For those who chose to register and pay on the first day of Camp, the cost will be $150 for Montana and $215 for Dakotas.

T-Shirt Size (Included if you complete registration 3 weeks or more BEFORE the camp you plan to attend; carefully select your size below.

The size you mark below. Shirts will be presented to you by your room leader.

Child Small

Child Medium

Child Large

Child XL

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Adult 4XL

Adult 5XL

Canteen Cards (non-refundable) can also be purchased at camp in the Canteen. Please purchase your canteen cards; sold by card in increments of $10. For example: one card is $10, two are $20, etc...

Please note that deposit is required upon completing your camper registration. The non-refundable and non-transferable deposit ensures your student has a guaranteed spot for their week of camp. If your church would like to help sponsor a portion or the remaining account balance, they are welcome to do so.

Camp Cost for each camper is NON-TRANSFERABLE. THIS WILL BE ENFORCED.

Refunds will be returned minus the $50 deposit on a case-by-case basis. All requests for refunds must be submitted to pastor@lighthousechurchdickinson.com

Shirt Size (Child Small-Adult 5x)*

Please type the shirt size in the above box

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