Bear Ridge Youth Camp Camper Application

Fees: $170 - ages 8 and older, $60 - ages 4-7 (parent or guardian MUST also be registered and attending. Please, no infants or toddlers).

For households with 4 or more persons attending, the 4th and subesquent registration fee is $90 per person.

Please send payment to 1724 Hooper Rd. Yuba City, CA 95993. Please send all payments in care of Bear Ridge Youth Camp, and be sure to include name of camper/staff in the memo.

Payment can also be made via PayPal @BearRidgeYouthCamp

Scholarships may be available, please contact FMBC Yuba city by June 1, 2024 for availability.

Camp Applications are DUE no later than June 15, 2024.

All payments are required by June 30, 2024.

Any questions contact the Director, Zack Dollins 530-632-3739, or Registrar, Amanda Lewis 559-301-1134

More details about camp will be sent after the application deadline!

NAME: Last*

First*

Middle*

Date of Birth*

Date

Age at Camp*

MF

Home Address*

Apt

City*

State*

Zip*

Cell Number*

Please enter a valid phone number.

Home Number

Please enter a valid phone number.

Alternate Number

Please enter a valid phone number.

Email Address*

example@example.com

Church*

NAME*

Relationship to Camper*

Address*

Apt

City*

State*

Zip*

Cell Number*

Please enter a valid phone number.

Alternate Number

Please enter a valid phone number.

Alternate Contact: Name*

Cell/Alternate Number*

Please enter a valid phone number.

DISEASES/ILLNESSES

CHRONIC/RECURRING CONDITIONS

ALLERGIES

PLEASE EXPLAIN IF OTHER IS CHOSEN

If any boxes are checked please explain

Additional Information about your child that will help us better care for them Ie ADHD ADD Sleeping Issues or Behavioral Issues etc

Operations or serious injuries (list type and approximate date)

Chronic or recurring illness or medical conditions

Any prescription medication being taken?*

YesNo

If yes, list names of medication{s) and what condition they are for and how frequently they are administered (Note: All camper medications including over the counter medications, must be turned in to the Camp Nurse upon arrival at Camp and will be administered by the Camp Nurse)

Name of Medication

Condition

Dosage Frequency

Name of Medication

Condition

DosageFrequency

Name of Medication

Condition

DosageFrequency

Name of Medication

Condition

DosageFrequency

Dietary Restrictions*

YesNo

if yes explain

Name of Physician*

Insurance Carrier attach copy of card below*

Policy#*

Name of Policy Holder*

Authorized Medicines and Health Information: If you wish the above minor to have access to any medication provided by you, you must complete the section of this page indicating the name of the medication, the condition it is taken for and the dosage or frequency to be dispensed. All medications for minors will be stored with the Camp Nurse and returned to the camper at the end of the camp. / further authorize the Camp Nurse to dispense (or withhold) medications and medicines as indicated above.

Liability Release Form (Release of All Claims)

In consideration for being accepted by First Missionary Baptist Church for participation in the 2024 Youth encampment, I do hereby release, forever discharge and agree to hold harmless the First Missionary Baptist Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating at Bear Ridge Youth Camp or activity including recreation (including but not limited to: hiking, sports) and work activities. The undersigned further hereby agrees to hold harmless and indemnify said church, it's directors, employees and agents for any liability sustained by said acts or said participant including expenses attending thereto. The Undersigned further consents to the administration of first - aid and/or doctors care or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify First Missionary Baptist Church of Yuba City, its directors, employees and agents from any failure to act on the part of the chosen to administer medical care on the behalf of the participant.

Notice: Pictures will be taken during camp activities and could be posted on social media or other outlets

Signature*

Printed Name*

Date*

Date

Name of Participant (If Different from Above)

Bear Ridge Youth Camp Camper Application

Camper Information

PARENT/LEGAL GUARDIAN/EMERGENCY CONTACT INFORMATION

HEALTH HISTORY