Camp Registration Form

Twin States PCG Youth Camp Registration Form - Worker

Fill out the form carefully for registration
Worker Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Worker E-mail
example@example.com
Mobile Number
Worker Tshirt Size
*Please note: Worker fees do not include a tshirt. Please add $20 if you would like a shirt.
Parent/Guardian Name (if under 18)

First NameLast Name
Parent Mobile Number
Work Number
Church Name*
Pastor Name*
Are you currently taking any medication?*

YesNo
If yes to above, please list all medications worker is currently taking including administration instructions: (Please send all meds in original pharmacy containers in a clear bag with name)
Are there any illnesses, disease, or special medical circumstances that we need to know about the worker? If worker is currently under doctor's care, please list physician information in case of emergency.
Does worker have any of the following?

GlassesContact lensesHearing Aids
Does worker have medical insurance? Please type yes or no. If yes, please list current insurance information.*
Emergency contact name & phone number*
Additional Comments
The undersigned participant and his/her parent/legal guardian agree to hold Twin States PCG its employees, officers, and volunteers, from any claims, damages, losses, and/or expenses arising out of participation in camp activities and to assume all liability for any and all personal injury, bodily injury, illness, or property damage that occurs as a result of participation in such activities. Signature of this agreement also warrants that participation in this camp is voluntary and that the participant and undersigned understand the inherent risks involved in the camp’s activities. The participant understands that these risks exist despite the camp’s safety precautions and procedures and the participant agrees to obey all rules and policies mandated by camp personnel. The undersigned participant and his/her parent/legal guardian warrant that he participant is physically fit and able to participate in all camp activities and that there is and will be adequate health insurance coverage in force for the term of the camper’s attendance. The undersigned further verifies that the health insurance covers any and all accidents, injuries or illnesses that may result from participation in the camp activities and that the camp’s medical form has been completed, signed, and dated. The undersigned participant and his/her parent/legal guardian give the Twin States PCG and its representatives permission to provide emergency medical response and/or treatment as needed for any injury or illness that may occur while the participant is involved in camp activities and agree to release the Twin States PCG and its representatives from all liability arising out of such treatment. In addition, as the participant’s parent/legal guardian, I hereby give the undersigned participant permission to participate in any and all district approved camp activities either on or off the campgrounds.*

Agree
Worker Signature*

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By typing your name below, you are agreeing to follow the above camp rules. You certify that all information given is correct and complete. *

First NameLast Name
Parent/ Legal Guardian Full Name & relationship to worker (if under 18):
WORKER AGREEMENT: I AGREE TO OBEY ALL CAMP RULES AND REGULATIONS WHILE ENROLLED AT CAMP.*

Yes
Worker Parent Signature (If under 18)*

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Date*

MonthDayYear
Date
Worker fee is $50. This includes the full week of camp, all regular meals, & activities. Additional money may be needed for snacks at canteen. If worker would like to purchase a tshirt, please pay $20 extra. How will your worker's fee be paid?*
Click here to pay online now!

*Please choose Youth Camp from drop down menu when submitting payment
Should be Empty:

Twin States PCG Youth Camp Registration Form - Worker