Urban Kids Camp 2024 Registration Form

URBAN KIDS CAMP/NEXT STEP Summer Camp Registration, August 1st-4th, 2024
Camper or Jr. Counselor (12 grade thru 20yrs of Age ) or Adult Volunteer's Name

(Adult Volunteers such as Camp Counselors Applicants/Program Leaders/Chaperones please fill out all places that apply)
This is a:*

Camper RegistrationJr Counselor Application/RegistrationAdult Volunteer Application/Registration (18 yrs old or older)
First Name*
Middle Name
Last Name*
Gender*

MaleFemale
Camper/Jr Counselor/Adult Volunteer Contact Information
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email*
example@example.com
Address*
City*
State*
Zip*
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Birth Date of Camper

MonthDayYear
What Grade will camper/jr counselor be entering in the Fall (if adult volunteer, select that option):*
What Age Range is Adult Volunteer/Chaperone:
All Adult Vounteers, Counselors & Chaperones will have to Complete a (or have a current) Background Check

Cal-Pac Camping/UKC Ministries will provide this Background Check/Screening. You will receive a separate email from Cal-Pac Camping with instructions on how to complete this requirement.
Cabin Buddy

List first and second choice, not all requests are guaranteed.
Cabin Buddy #1
Cabin Buddy #2
Parent or Legal Guardian Information
Name of Parent/Legal Guardian
Relation
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email
example@example.com
Name of Parent /Legal Guardian 2
Relation 2
Cell Phone 2

Area CodePhone Number
Home Phone 2

Area CodePhone Number
Work Phone 2

Area CodePhone Number
Church Information
Church you attend or Organization you're part of?
Church District/City or Organization City
Church or Organization you are coming with (if any)
Email Confirmation
Parent, Guardian or Adult Volunteer Email (camper confirmation will be sent by email, if left blank it will be mailed)*
Camper's Email
Other Information
What is your T-Shirt Size?*
How did you hear about Urban Kids Camp/Next Step?
First Time Camper?

YesNo
Health Information

A health officer, nurse or first aid certified person is on site at all times.
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration please see the health officer at that time. Please bring all medication in ORGIANAL CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that campers name and the correct dosage.
Is camper or adult volunteer free from infectious desease or conditions?*

YesNo
Are immunizations up to date?*

YesNo
Date of last tetanus shot
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper or adult volunteer should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
⁸⁷
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.*
Passenger Van Transportation to Camp Wrightwood will be available from two locations. Please indicate which pickup site you or your camper will use:*

Crenshaw United Methodist Church (3740 Don Felipe Dr, Los Angeles, CA 90008)First United Methodist Church of Pacoima (12550 Van Nuys Blvd, Pacoima, CA 91331)I will use other transportation to drop off and pick up our camper(s) from the Camp Wrightwood:1401 Linnet Rd, Wrightwood, CA 92397
Payment Information

$99.00 Registration Fee Due per Camper/Jr. Counselor. A few limited $49 scholarships are available for those with true need. If accepted, your registration fee be reduced to $50.00
For those who have a true need, we have a limited number of scholarships available. Are You Requesting a $49.00 Scholarship?

YesNo
Please State Reason for Scholarship Request
Method of Payment
I will Go to SOUMC.ORG and click the "Donate Now" Button Or use this link: https://soumc.org/giving/ (Use the "Urban Kids Camp" Fund Registration Fee+Processing Fee of $99 or $50 per camper (If Scholarship Application Approved)I will Call with a Debit or Credit CardI will mail a Check to SOUMC
If paying with a check, please send the registration fee as soon as possible. You can pay multiple registration fees with one check. In memo, please put "UKC" & the camper(s) name. The registation fee is due anytime before the first week of camp. If you have any questions or want to Pay Registration Fee by Debit/Credit Card contact Jean Castro at 818-789-0351 (Mon 10am-1pm, Tues-Fri 10am-4pm)

Make Check Payable to: "SOUMC" with "UKC" in the memo

Mail Check to: Sherman Oaks UMC, 14401 Dickens St., Sherman Oaks, CA 91423
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)
Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks of Camp
MEDICAL RELEASE & HOLD HARMLESS
I Do hereby authorize bona fide officials of the Urban Kids Camp, Next Step and Harambee, and Cal-Pac Camping staff and volunteers as agents for the under-signed to consent to X-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable and is to be rendered under the provisions for the MedicalPractice Act by the medical staff of a licensed hospital whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

I hold harmless the California-Pacific Conference, its Boards, officers, members, clergy, staff, agents and volunteers from any and all claims, losses, costs, obligation and liabilities for injuries to any persons or for damages to or loss of any kind in any way arising out of participation of the above mentioned person, whether or not arising from any alleged negligence, fault or legal liability of the California-Pacific Conference, its Boards, officers, members, clergy, staff, agents and volunteers.

This authorization shall be effective through Aug 15th, 2024

CALIFORNIA CIVIL CODE SECTION 25.8 Cal-Pac Camps may take photos and videos during camp which may later be used for marketing and promotional purposes within the bounds of the California-Pacific Conference. If you would not like your child appearing in any of these materials, please request this in writing to: Cal-Pac Camps c/o Wanda Bethea, PO B ox 6006 , 110 South Euclid Ave., Pasadena, CA 91102.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites. I authorize Cal-Pac UM Church, Camp Ministries and Urban Kids Camp to use my camper's picture, testimony, and video in any promotional material (web, print, or media). My child may recieve any e-mails from the camp.
Signature*

Clear
Date*

MonthDayYear
Date
Electronic signature, please initial*
If you have additional questions or anything else to share with our leadership team, please state it here:
Should be Empty:

URBAN KIDS CAMP/NEXT STEP Summer Camp Registration, August 1st-4th, 2024

Camper or Jr. Counselor (12 grade thru 20yrs of Age ) or Adult Volunteer's Name

Camper/Jr Counselor/Adult Volunteer Contact Information

All Adult Vounteers, Counselors & Chaperones will have to Complete a (or have a current) Background Check

Cabin Buddy

Parent or Legal Guardian Information

Church Information

Email Confirmation

Other Information

Health Information

Payment Information

Method of Payment

Camper Release

MEDICAL RELEASE & HOLD HARMLESS