KIDS CAMP 2025

Important Information. By signing this form you agree to the following:

1. $100 deposit is due March 1st. DEPOSIT IS NON-REFUNDABLE.

2. I will sign up for the remind group text by texting phone number 81010 the message @2025kid and will check the Kids Camp Facebook page for information, packing list, etc.

Camper Name*

Birth date*

Age*

Gender at Birth

FemaleMale

Grade (24-25 school year)*

T shirt size*

Camper Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of parent(s) or guardian(s)*

Parent Cell Phone*

Parent Work Phone*

Parent Email

example@example.com

Emergency contact name (other than parent/guardian)*

Emergency contact relationship to the camper:*

Emergency Contact Cell Phone Number: *

Please enter a valid phone number.

Emergency Contact Home or Work Phone Number*

Please enter a valid phone number.

If NEEDED, can the emergency contact for your camper pick them up early?*

YesNo

Does your child have any allergies to medications, food, or other?*

YesNo

Are all immunizations current with State Law?*

YesNo

Does your camper have an EpiPen?*

YesNo

Does your camper have an inhaler?*

YesNo

My Camper may be given over-the-counter, non-prescription medications or applications, not to exceed recommended dosage for; stomach discomfort, burns, cuts, insect bites, rashes, ache, fever, cough, congestion, etc.*

YesNo

Please list any exceptions to the over-the-counter non-prescription medications:

Does camper have any of the following:

Please explain any checked items.

All medications, prescription, and over the counter medication MUST be collected by the CHURCH leader and brought to the camp nurse at registration in their ORIGINAL CONTAINER. A $5 NURSES FEE WILL BE ADDED to all campers requiring medication. Does your camper require medications.*

YesNo

Please list any medication (name/dosage/instructions) the camper is taking. Put N/A if none. *

Insurance Company *

Insurance Phone Number*

Insurance Group Number*

Insurance Policy Number*

Insured's Name (Policy Holder/Guarantor)*

Can your camper swim?*

YesNo

Are there any activities your camper CANNOT participate in? such as: rock wall, climbing, lake swimming, pool swimming, gym games, outdoor games, trampoline jumping, etc.*

YesNo

If you answered yes to the previous question, what activities are prohibited for your camper?*

Minor Participation Authorization and Consent to Emergency Medical Treatment Form

I, the undersigned, certify that I am the parent or legal guardian of the above listed child (hereafter the “minor child”). I hereby give my consent to have my minor child participate in the following activity of Dixon Assembly of God: Kids Camp (hereafter “the activity”) on or about July 7-11, 2025

I recognize that there are risks involved in participating in this activity and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in this activity.

To the fullest extent permitted by law, I release the Dixon Assembly of God, its trustees, officers, directors, employees, agents, and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Dixon Assembly of God, its trustees, officers, directors, employees, agents, and representatives from any claims arising out of my minor child’s participation in the activity.

EMERGENCY TREATMENT PERMISSION/COOPERATIVE AGREEMENT As parent or guardian, I have given permission for my child to attend camp, and I hereby authorize and request any doctor, medical clinic or hospital emergency room physician to administer such treatment and to do any procedure in their judgment that may be necessary. I fully understand that the camp insurance is secondary coverage with a maximum benefit of $5,000 per incident, and that I will need to file my own insurance first. I also understand that the camp insurance covers ACCIDENTS ONLY and that I accept full responsibility for any charges related to causes other than accidents, or charges beyond the $5,000 maximum of the camp insurance. I also hereby give permission to the Dorm
Leader and/or other member of the camp staff to inspect the contents of any or all of my child’s personal belongings, and to withhold and/or dispose of any improper or illegal contents. Permission is given to SMDC Assemblies of God to use photographs (individual or group) and/or multimedia images and recordings in the best interest of SMDC Assemblies of God. Your signature
signifies you understand and support your student’s involvement in the Southern Missouri District Camp and will abide by all of the guidelines set by Southern Missouri District. Is there any information we should have regarding the welfare of this camper (handicaps, restrictions on activities, diets, allergies, diabetes, mental or emotional issues, etc.)?

As part of this activity, children may be photographed, interviewed, and/or videotaped by representatives of Dixon Assembly of God’s media outlets (newspaper, church projector screen, etc.) as part of our recognition program. Any information or images obtained from church activities may be reproduced by Dixon Assembly of God and/or public media for use in advertising, publicly or church activities, including but not limited to church publications (church directory, church website, church social media, and newspaper), videos, print (newspaper), and/or radio/television news. Dixon Assembly of God classifies this as directory information pertaining to FERPA. Your choice will remain in effect for any activity at Dixon Assembly of God unless you provide written notice. If you DO NOT wish your child to be photographed, interviewed, or videotaped for media use, please notify Dixon Assembly of God in writing.

TRANSPORTATION PERMISSION SLIP: I give my permission for the camper listed above to be transported by the Dixon Assembly of God Church Van/Transportation Ministry. In event of an emergency, someone from the Dixon Assembly of God Church
Camp Ministry team will contact me at the phone number I have provided below. If I cannot be contacted at the number, the person/s in charge from Dixon Assembly of God have my permission to seek medical attention from my child at the nearest medical facility to their location at the time of the emergency. I understand that I am responsible for all medical expenses concerning my child. I also agree that my child is to follow the van/transportation rules as well as church rules or I will be responsible for picking my child up at the scheduled event. My child is also required to stay at the scheduled event(s) until the Dixon Assembly of God Van/Transportation Ministry brings my child home, unless arrangements are made prior to the event and placed in writing and signed by me.

RULES:

1. Do to others as you have them do to you.

2. Remain seated with seat belt always on.

3. Respect other riders, the driver, and the vehicle.

4. Keep voice levels down.

5. Stay at the scheduled event, only leaving with the Dixon Assembly of God Van/Transportation Ministry.

This material is for information only and is not intended to provide legal or professional advice. You are encouraged to consult with your own attorney or other expert consultations for a professional opinion specific to your situation. GuideOne Insurance (07.01.08)

I have read the above information*

Yes

PAYMENT IS REQUIRED FOR REGISTRATION TO BE CONSIDERED COMPLETE. Which form of payment do you plan to make?*

CashCheck written to Dixon Assembly of GodVenmo @Brandi-Martin-87

Important Information. By signing this form you agree to the following:

1. $100 deposit is due March 1st. DEPOSIT IS NON-REFUNDABLE.

2. I will sign up for the remind group text by texting phone number 81010 the message @2025kid and will check the Kids Camp Facebook page for information, packing list, etc.

Parent/Guardian signature*

Please verify that you are human*

Kids Camp

Medical & Activity Information