Kids' Camp Registration

NORTHEAST DISTRICT WESLEYAN KIDS CAMP 2026

CAMP REGISTRATION AND MEDICAL INFORMATION
Important Camp Information:
- Northeast District Kids' Camp 2026 will be held at Pinebrook Retreat Center located at 5339 Pinebrook Rd, East Stroudsburg, PA.
- Kids' Camp is going to be a week filled with fun, excitement, worship, and lots of time to grow together in our relationships with Jesus! We can't wait to see you at camp!
- Registration Deadline: July 17th
Next Steps:
- Parent/Guardian: Once you submit this registration form, you will receive an email with a PDF of your form. Print the form and submit it to your church leader, along with the $299 registration fee (checks should be made to your local church).
- Church leader: Collect the registration forms along with the registration fees. Mail all forms along with one church check (made payable to "Northeast District Kids' Camp") to:
Northeast District

6737 Cetronia Road

Allentown, PA 18106
Camp Dates: August 5-9, 2024

Check-in time: Monday at 4 pm

Check-out time: Friday at 1 pm
Name of Church with which you are attending:*
Please list the email address of your children's pastor or leader coordinating camp (children's pastor, senior pastor, camp coordinator)*
example@example.com
Camper Information:
Camper's Name*

First NameLast Name
Grade Completing*
Age*
MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information

Parent/Guardian Information is required for at least one adult. The form requires either Father/Guardian information OR Mother/Guardian information. Information for both can be listed.
Father's Name (or Guardian)

First NameLast Name
Mother's Name (or Guardian)

First NameLast Name
Parent/Guardian Email Address (Camp information will be sent to THIS email, including the PDF of your child's registration. Please print the PDF and submit to your church leader.) *
Father's CELL Number*
Father's WORK Number
Mother's CELL Number*
Mother's WORK Number
Home Number*
Additional Emergency Contact (other than parents/guardians)
Relationship to Camper*
Emergency Contact's Name*

First NameLast Name
Emergency Contact's Number*
Alt. Phone Number
OTHER INFORMATION NEEDED
YESNO
YESNO
Please mark your child's TSHIRT size. *
SHIRTS ARE PROVIDED IN COST OF CAMP
We want to make you aware that pictures will likely be taken of your child while at camp. If there is a legal or confidentiality issue involving your child/family and your child's picture should not be shown on the internet, please let us know below. Thank you!
YESNO
If yes, please explain:
My child may NOT be released to the following people (custody, etc.)
We recognize changes may occur during the week of camp. If someone other than the person your child is expecting needs to pick him/her up, please send a signed note with that person.

******** HEALTH INFORMATION FOR THE NURSE ********

Type "N/A" if the question is not applicable.
Allergies - food, medications, bees, etc.*
Typical Reaction to the allergy
Treatment for the allergy
****ALL medication must be brought to camp in a bottle that is completely LABELED by a pharmacist. ALL medication must be turned into the camp nurse upon arrival at registration. (This includes over the counter medication). Campers are not allowed to self medicate at camp and cabin leaders are not allowed to administer medication.***
List all medications your child takes including name, dosage, schedule, and reason for taking*
YESNO
Date of Last Tetanus Shot
Please list any medical and/or behavioral information that camp staff should be aware of: *
Physician's Name*
Physician's Phone Number*
Health Insurance Company*
Group Number*
Policy Number*
Thank you so much or this information. You and God have entrusted your child into our care, and we take that very seriously. Thank you for enabling us to do the best that we can.
SIGNATURE AND AUTHORIZATIONS
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Northeast District Kids' Camp and its affiliates including Directors, Cabin Leaders, and other leaders of the camp to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
YESNO
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Northeast District Kids' Camp during the selected camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Northeast District Kids' Camp and all its respective leaders, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Northeast District Kids' Camp and the Northeast District of the Wesleyan Church, including all leaders and affiliates, all participants, sponsoring agencies, and, if applicable, owners and lessors of premises used to conduct the event. I realize there is a risk of being injured that is inherent in all camp activities.
YESNO
Clicking the "SUBMIT" button below serves as your online signature for this registration. However, we do require a physical copy for use by the nurse.

Once you click "SUBMIT" you will receive an email from Northeast District Kids' Camp. That email will include a PDF copy of your registration form. Please print the PDF document and sign it at the bottom. Turn the signed form and the $299 registration fee in to your church leader.

Thank you!
I authorize that I am the parent and/or legal guardian of the camper being registered and I certify that all the information given on the registration form and the medical form is true to the best of my knowledge. I also certify that I have read the "Medical Release and Authorization Statement" as well as the "Informed Consent and Acknowledgement" Statement and have checked my appropriate response to each.

Electronic signature required below.
Parent/Guardian Signature*
FOR OFFICE USE ONLY
*****FOR OFFICE USE ONLY*****

CABIN ______________________

AMOUNT PAID ________________

CHECK NUMBER ______________

NAME ON CHECK _____________

BALANCE DUE ________________
IGROUP CHOICES
CABIN _______________
*****FOR OFFICE USE ONLY*****

Prn ________________________ ________________________

___________________________ ________________________

___________________________ ________________________

___________________________ ________________________

____AM ____LUNCH ____SUPPER ____AS NEEDED ____QHS
Should be Empty:

NORTHEAST DISTRICT WESLEYAN KIDS CAMP 2026

OTHER INFORMATION NEEDED

SIGNATURE AND AUTHORIZATIONS

FOR OFFICE USE ONLY