Camp David So IN Camper Registeration

Girls Week 2024 Camper Application

June 17th-21st, 2024
Welcome to Camp Kerith of Southern Indiana! We can't wait to get to know your camper better, and we hope camp is a fun, safe, and life-changing experience. Whether this is your camper's first year or fifth, we hope this is a summer we will never forget.

Camp Kerith is a camp designed for the children of prisoners, children living or who have lived with substance addiction in the home, or children who have experienced high levels of trauma in their lives.

We desire to create a camp experience around those specific needs and begin a mentoring process that continues year-round. If you do not believe your camper qualifies under these guidelines, you may continue the application and fill out the Family History questions to the best of your ability. We will review all applications and contact you as they are processed.

To begin the application process, you will need to gather the following information:
- Family & Emergency Contact Information
- Write a Brief Family History
- Campers Medical Information
Once the following has been gathered, the Application will only take 10-15 minutes to complete per application. You must complete an application for every camper you wish to send to Camp Kerith of Southern Indiana.

Space is limited and may not be guaranteed for all applicants. If you are concerned about limited space, please call the office at 812-945-0886.

If the desired week of camp is filled, your camper will be put on a waiting list until a camper slot becomes available. Camp Leadership may also recommend the Day Camp Program, depending on the camper's history with the program or emotional/sensory awareness.

Thank you again for being a part of our camp family. We hope to see you at camp very soon.

Camper Information
Camper's Full Name *

First NameLast Name
Nickname
Age *
Date of Birth*
MM/DD/YYYY
Family Information
Name of Parent or Legal Guardian Signing Camper Up For Camp *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*

Area CodePhone Number
Text Reminders

YesNo
Secondary Number if Available

Area CodePhone Number
Email*
example@example.com

Emergency Contacts
Emergency Contact #1: Relative *

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact #2: Close Family Friend *

First NameLast Name
Phone Number*

Area CodePhone Number
Please use the space below to add any names of additional birth parents, co-parents/guardians, family members or friends and their relationship to the camper that may be important to your family story, good or ill.

Transportation
Please Pick One:*

I will provide transportation for my child to and from campMy child(ren) will need to ride the van from my nearest pick-up spot
Camp starts at 11:30 am on Monday and ends at 1:00 pm on Friday.
Resource Share

Camp Kerith and Kerith Family Recovery is a proud partner with Clark & Floyd County Cares. CCC and FCC offers support by connecting families to further resources including housing and utilities support, professional counseling for adults and youth, meal support and so much more. If your family would like access to further resources outside of Camp Kerith support, use the link below.
Please Choose One Option

I would like an Clark & Floyd Co Cares associate to connect with meI do not need further resources at this timeOther
Parental Permission & Release
"I understand that while attending Camp Kerith of Southern Indiana, my child may be involved in various activities, including, but not limited to, swimming, horse rides, obstacle courses, and other traditional camp activities.

I understand the mission of Camp Kerith of Southern Indiana is to provide a faith-based, but not imposing, camp program where one can experience love, find hope, and grow in a relationship with Jesus Christ. I grant my child permission to attend and participate fully in all camp activities.

I have instructed my son/daughter to obey the rules of Camp Kerith of Southern Indiana. I understand that should my child become disruptive, I must arrange to pick them up.

Parent/guardian of the participating child hereby grants Prison Fellowship Ministries (“PFM”), its affiliates, and agents irrevocable permission to use, record, and reproduce the image and likeness of his/her participating child in any manner. All media now or hereafter known, for any purposes (including advertising and promotional use), in perpetuity throughout the world, without restriction as to alteration. The parent/guardian and participating child give this consent with no claim for payment. I also permit Camp Kerith of Southern Indiana to use camp pictures of my child in promotional and sponsorship material*."

*no children in the foster care system will have their photos or videos used for promotional purposes.
Name of Parent or Guardian: *

First NameLast Name
Relationship to the Camper*
Date Signed*

MonthDayYear
Date
Should be Empty:

Girls Week 2024 Camper Application

Camper Information

Family Information

Emergency Contacts

Scholarship

Inmate Verification

Family History

Campers Medical Information

Medical Permission & Release

Lice Policy

Transportation

Resource Share

Parental Permission & Release