Summer 2025 Camper Registration

We are so excited to have you join us in Aug for our 2025 Youth Summer Camp.

Lion of Judah

The camp will be Aug. 10th-15th of 2025. We will begin check-in at Spring Valley Bible Camp on Sunday at 2 pm and will conclude camp on Friday at 11 am.

This registration form will help us have all the needed information to prepare for an amazing camp together. You will be asked to complete your payment at the end of this form. Regular registration cost $385 until registration closes July 13th. Registration includes all lodging and meals for the weekend, swag and more.

We can't wait to meet all of our new friends at Midwest Messiah! Until then, if you have any questions, you are welcome to email us at MessiahMidwest@gmail.com.

Camper Name*

First NameLast Name

Camper Email*

Confirmation EmailPlease retype your email to confirm.

Camper Phone Number*

Area CodePhone Number

Birth Date*

MonthDayYear

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

T-Shirt Size (Adult Sizes)*

Congregation/ Church

Congregational Leader

Parent 1 Name*

First NameLast Name

Parent 1 Relationship*

Parent 1 Phone Number*

Area CodePhone Number

Parent 1 E-mail*

Confirmation EmailPlease retype your email to confirm.

**The above email that will be used to send out all camp information.

Parent 2 Name

First NameLast Name

Parent 2 Relationship

Parent 2 E-mail

example@example.com

Parent 2 Phone Number

Area CodePhone Number

Emergency Contact Name*

First NameLast Name

Emergency Contact Relationship*

Emergency Contact Phone Number*

Area CodePhone Number

I, (participant/parent/legal guardian if participant is under 18 years old) authorize my child to fully participate in the Midwest Messiah Summer Camp 2025 and related activities. I understand the activities are not without some inherent risk of injury.

In consideration of my child's right to participate in this activity, I agree to release, waive, discharge, agree not to sue, and to hold harmless for any and all purposes Midwest Messiah and their officers, employees, agents, and volunteers. I release Midwest Messiah from any and all liabilities, claims, or injuries, including death, that may be sustained while participating in this activity, including swimming, including traveling to, from, and for the activity, or while on premises owned or controlled by Midwest Messiah, including injuries sustained as a result of the negligence of Midwest Messiah. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of Midwest Messiah. I further agree to indemnify and hold harmless Midwest Messiah for any loss, liability, claim, or injury caused by me (my child) while participating in this activity, including traveling to, from, and for the activity, or while on premises owned, leased, rented, controlled, or operated by Midwest Messiah.

I also give my permission for me (my child) to receive any emergency medical treatment by a
healthcare professional, including emergency medical transportation, which may be required for injuries sustained by me (my child).

I agree to indemnify and hold harmless Midwest Messiah for any costs incurred to treat me (my child), even if a Midwest Messiah officer, employee, agent, or volunteer has signed hospital documentation promising to pay for the treatment.

Furthermore, I (my child) agree to follow all instructions and procedures in order to maintain a
maximum level of safety.

Participant's Name:*

First NameLast Name

Participant's Signature*

Date*

Date

Parent Legal Guardian Name: (If Participant is under 18)

First NameLast Name

Parent/Legal Guardian Signature

Date

Check One*

YouthAdult

Event: Midwest Messiah Youth Summer Camp Aug 10-15, 2025

The proposed activity provided by Midwest Messiah requires participation in physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you and
cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart
related or other diseases. Therefore, all participants must be free of medical or physical
conditions which might create undue risks to themselves or any others who depend on them. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination.

Does the camper have any allergies, chronic illnesses, or medical conditions? If yes, please answer the next question.*

YesNo

List allergies, chronic illnesses, or medical conditions.

Does the camper use an inhaler or carry an epipen? If yes, please answer the next question*

YesNo

Please list inhalers used or needs of your epipen.

Dietary needs outside of a Biblically clean diet

Does the camper plan to bring medications to camp?*

YesNo

Have you had or do you currently have any heart problems:*

YesNo

Do you frequently suffer from pains in your chest:*

YesNo

Do you often feel faint or have spells of severe dizziness:*

YesNo

Has a doctor ever told you that you have high blood pressure:*

YesNo

Are you a smoker:*

YesNo

Do you have arthritis, joint, or back problems :*

YesNo

Have you had any operations or serious injuries:*

YesNo

Do you have any chronic recurring illness or communicable diseases:*

YesNo

Are there any activities to be limited by a physician's advice:*

YesNo

Are you allergic to any medicines, insects, or pollens:*

YesNo

Do you have Epilepsy:*

YesNo

Do you have Diabetes:*

YesNo

Do you have any prescribed meal plan or dietary restrictions other than Biblically clean:*

YesNo

Please explain any yes answers.

Please check over the counter medications which camp personnel may administer as necessary:*

Are there prescribed medications currently being taken (please explain below)

Any other health related information.

Do you carry family medical/hospital insurance?*

YesNo

Carrier:*

Policy Number*

Policy Holder*

Carrier Phone Number*

Participant's Name*

First NameLast Name

Participant's Signiture*

Date*

Date

Parent Legal Guardian Name: (If Participant is under 18)

First NameLast Name

Parent/Legal Guardian Signature

Date

My Products

Camper Registration $385.00

Enter coupon

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Summer 2025 Camper Registration

Camper Information

Parent/Guardian Information

Emergency Information

RELEASE, WAIVER, AND AUTHORIZATION FOR MEDICAL TREATMENT

HEALTH STATEMENT

Medical Info

Health History

Medication

Insurance Information

Representation

Payment