Confirmation Camp Registration

Confirmation Camp Registration
Camper Information

Please submit one form per camper
Camper Name*

First NameLast Name
Date of Birth*

MonthDayYear
Grade Entering Fall 2025*
T-shirt Size (ADULT SIZES)*

SmallMediumLargeX-Large
Sex*

MaleFemale
Parent's Name (1)*

First NameLast Name
Parent Home/Cell Phone Number (1)*
Parent Work Phone Number (1)
Parent's Name (2)

First NameLast Name
Parent Home/Cell Phone Number (2)
Parent Work Phone Number (2)
Home Address*

Street Address

Street Address Line 2

CityState

Postal Code
If not a member of Shepherd - I came as a friend of:
I grant permission for my son/daughter to participate in Confirmation Camp. I agree to release and hold harmless Shepherd of the Hills and its employees and/or volunteers and Camp Lakotah and its employees from liability from any and all loss or expense, including costs and attorneys' fees, for any damages caused by injury to my son/daughter or his/her property resulting from participating in the Camp. I understand that photos of my son or daughter while at camp may be used for promotional purposes and/or posted on social media. I give permission to transport my child to camp and back home.
Parent's Signature*
Date*

MonthDayYear
Date

Health Form
Emergency Contact (other than the parent above)

In the case that we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent above).
Emergency Contact Name*

First NameLast Name
Work Phone Number*
Cell Phone Number*
Health History

AsthmaDiabetesConvulsionsHay FeverEpilepsyHeart ConditionFood AllergiesAllergic to HorsesBed Wetting
Other Allergies, Illnesses or Diseases
Chronic or Recurring Illness
Operations or Serious Injuries (Dates)
Recommendations and Restrictions while at Camp
Special Diet
Medication
Swimming or Boating
Ropes & Challenge Course or Climbing Wall
Strenuous Activities
Other
Health Insurance Company*
Policy Number*
Name on the Policy*
Important: Please notify your group leader if participant has been exposed to any communicable diseases during the three weeks prior to your arrival to camp.

Medical Authorization: This health history is correct so far as I know, and the person here in described has permission to engage in all prescribed camp activities, except noted by me or the examining physician. In the event of an Emergency, I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for me.
Parent's Signature*
Date*

MonthDayYear
Date

Authorization to Administer Medication Form
I hereby give permission for adult leaders from Shepherd to administer the following medication(s) to my child. Dosages will be administered according to directions on the package unless a physician directs otherwise.
Parent's Signature*
Date*

MonthDayYear
Date

Insurance Card
Please upload a copy of your insurance card.

Be sure to include images of BOTH sides of your card.
File Upload*

Cancelof

Confirmation Camp Code of Conduct
At Confirmation Camp, I will:
- Come with a great attitude!
- Respect people and people's property
- Listen when other people are talking
- Help out with anything I am asked to do (i.e. pick up, set up, clean up)
- Stay with the group
- Ask permission from an adult to go anywhere
- Refrain from displaying public affection
- Check in all medications, even items such as Tylenol, on Sunday afternoon (don't pack meds in bag, have them ready to check in)
- Not bring any items along that could harm myself or others
- Leave all electronic devices at home (i.e. cell phones, ipods, ipads, etc.)
- Follow the rules as outlined by the adult leader
I have read the Code of Conduct and plan to abide by these guidelines.
Student's Name (Printed)* Signature of Student*
I have read the Code of Conduct. I understand that if my son/daughter fails to abide by any of these expectations, I will be responsible for picking them up and transporting them home.
Parent's Name (Printed)* Signature of Parent* Date*

Opportunities for Parents to Serve
Please check all that apply.

I will provide snacks (turn in at registration).I will serve/attend camp Sunday - dinner on Monday.I will serve/attend camp Monday - Wednesday Morning.I will serve/attend camp the entire time (Sunday-Wednesday).I would like to speak with Chad about serving outside of the options listed above .
There is no fee for adults to attend.

Thanks for all you do! We appreciate your willingness to serve!
Name

First NameLast Name
Email
example@example.com
Youth's Name

First NameLast Name
Phone Number
Please enter a valid phone number.

Payment
Payment Options*

I agree to submit payment of $150.00 to Shepherd of the Hills (check or cash)I request Financial Assistance
Should be Empty:

Health Form