LIGHT Camp Application & Registration

LIGHT Camp Application & Registration | 2024

Southland can accept only a limited number of applicants into the two-week LIGHT program. To be eligible, each applicant must complete the following form and return it to SOUTHLAND. Applicants will be notified of acceptance beginning in April or before. The registration fee will be refundable if not accepted.
PERSONAL INFORMATION
Name*

First NameLast Name
Which LIGHT camp session would you like to attend?*
Gender*
Date of Birth*

MonthDayYear
Age by September 1st*
Email*
example@example.com
Grade in Fall 2024*
Shirt Size:*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Emergency Contact Phone Number*
Format: (000) 000-0000.
Please Upload a Recent Picture of Yourself:*

Cancelof
Roommate Request
Requests are not guaranteed

CHURCH INFORMATION & REFERENCES
Home Church*
Church Address*

Church Street Address

Church Street Address Line 2

Church CityChurch State

Church Zip Code
Pastor (or) Youth Pastor Reference:*

Pastor First NamePastor Last Name
Pastor (or) Youth Pastor Reference Email:*
Your camp registration will be sent to this email for your youth pastor's information and planning purposes
Adult or Mentor (not family) Reference:*

First NameLast Name
Email of Adult or Mentor (not family) Reference:*
example@example.com

MEDICAL INFORMATION
Date of Last Tetanus Booster

MonthDayYear
Date
Prescribed Medications Taken Regularly
Specific Allergies>Type of Reaction>Treatment Given
Food allergy information

Southland Ministries understands the needs of food-allergic campers. The dietician is able to safely and reasonably guide and accommodate campers. Food allergies that are life-threatening will be managed by our kitchen staff. We cannot, however, accommodate for dietary preferences. In these cases, we ask that the parent/guardian send, with the camper, a cooler/container filled with the foods needed for his/her time at camp. We will be happy to allow the sponsor to help your camper with his/her needs in these areas. Thank you for your cooperation in this matter.
Diagnosed Medical Conditions (e.g. asthma, diabetes, etc.)
YesNo
Family Physician

Dr. First NameDr. Last Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Specific Restricted Activities + Reasons for Restrictions
Medical Insurance Company
Insurance Policy Number

POLICIES & AGREEMENTS
Camper Agreement:
Camper Signature:*

Clear
Parent/Guardian Agreement:
I understand that every effort will be made to contact parents or guardians of campers. In the event I cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment, order injection, anesthetize or perform surgery deemed necessary for my child. I affirm that the medical information on this form is complete and correct.I give permission for my camper to be included in any photo, recorded images or any other transmission or reproduction for the purpose of Southland Ministries promotion.I have fully read the Camp Information & Policies (linked above) and realize that I am responsible to maintain the standards established by Southland Christian Ministries. I understand that action will be taken if camp policy is not upheld.I believe the applicant has made every attempt to be truthful and fair in his or her answers in the LIGHT camp application.
Parent/Guardian Signature:*

Clear
Parent/Guardian Email (for reference):*
example@example.com

My Products*

LIGHT Camp Registration Fee

The registration fee is non-refundable and non-transferrable. Only if the applicant is not accepted will it be refunded.

$25.00 Quantity

LIGHT Camp Full Registration (includes $25 registration fee)

$425.00 Quantity

Total

$0.00

LIGHT Camp Application & Registration | 2024