Youth Camp Registration 2025

Youth Camp Registration 2025

Mon-Wed, August 4-6th, 2025
*You have not completed signup until you have filled out all required fields and pressed the "Submit" button at the bottom of this page.*

For help filling out the form, you can contact Pastor Kirby at 225-354-9986
Youth/Participant Information
Youth/Participant Name*

First NameLast Name
Shirt Size (For Camp Shirt)*
Grade entering in the Fall*
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Legal Guardian Name (If adult leader, just put self)*

First NameLast Name
Contact Information
Phone Number*
Email Address*
Health Information
Is the above named youth allergic to any medication?*

YesNo
If yes, please specify:
Are they currently taking any medication?*

YesNo
If yes, list medication and reason it is taken:
Please list any dietary/health concerns we should be aware of:
Date of last Tetanus inoculation
Health Insurance Information
Insurance Company:*
Policy Number*
Insurance Company Phone #*
Primary Care Physician*
Physician Phone #*
Emergency Contacts
Parent/Guardian (If adult leader, just put your preferred emergency contact)*
Phone Number*
Please enter a valid phone number.
Parent/Guardian
Phone Number
Please enter a valid phone number.
Other Emergency Contact
Phone Number
Please enter a valid phone number.
Is there any other information that our youth leaders need to know about the participant?
Permission/Waiver Acknowledgement

Functions and Activities

It is my understanding that participating in the programs and recreational and other activities of Victory Harvest Church is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability

By signing this Permission/Waiver Form, I expressly warrant that the youth named above, or I (if I am a participant) am capable of withstanding both the physical and mental demands of children’s church activities. I also expressly assume all risks of the child, or me, participating in these activities, whether such risks are known or unknown to me at this time. I further release Victory Harvest Church and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have, or that I may have, against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against Victory Harvest Church or its ministers, leaders, employees, volunteers, or agents.

I further agree to indemnify and hold harmless Victory Harvest Church and its ministers, leaders, employees, volunteers, or agents from any and I further agree to indemnify and hand all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child, or myself, during such activities.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above or I (if I am a participant) may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Victory Harvest Church to seek and secure any needed medical attention or treatment for the child named above, or me (if I am a participant) including hospitalization, if in the agent’s opinion such need arises—and in doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment.

I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Special Events and Field Trips

I understand that the youth named above, or I, will be participating in activities from January 1 2025, through December 31, 2025. I understand that during this period, my child/ward or I (if I am a participant) may take part in activities such as: cell group activities, special outings, camps, trips, outreaches, field days, work days, or other activities consistent with the purposes of the church.

Publicity

On occasion, Victory Harvest Church takes photographs or makes an audio or videotape recording of children and/or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in Victory Harvest Church publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our church may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above to be used, distributed or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media.
IF THE PARTICIPANT IS A MINOR

I, the undersigned parent of the above participant, who is under 18 years of age, have read the above Permission/Waiver Form and am fully familiar with the contents thereof. Permission is given for this child to participate in all Victory Harvest Church activities between January 1, 2025 and December 31, 2025.

I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child and agree that this Permission/Waiver Form shall be binding upon me, my family heirs, legal representatives, successors, and assigns.

Confirmation

By signing below, I agree to the contents of this form.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian of Youth(if under 18) or Adult Participant*

First NameLast Name
Today's Date*

MonthDayYear
Date
Signature of Parent/Guardian*

Powered by Jotform SignClear
eSignature Acknowledgement*

I agree that my electronic signature is legally binding and has the same force and effect as a handwritten signature.
2025 Camp Cost
Camp this year will be $150/person.

Your child's spot at camp is not reserved until a $50 deposit is put down. You can pay cash or check in person (made to Victory Harvest Church) or pay online at victorygive.com.

If paying online or via check, please add a message to the payment like this: "Youth Camp- Child's Name"

The total remaining balance will be due July 6. If you are unable to cover the cost of camp and would like financial assistance, please indicate in the checkbox below.
Financial Assistance

I would like financial assistance for Youth Camp
Should be Empty:

Youth Camp Registration 2025

*You have not completed signup until you have filled out all required fields and pressed the "Submit" button at the bottom of this page.*

Youth/Participant Information

Health Information

Health Insurance Information

Emergency Contacts

Functions and Activities

Release of Liability

First Aid and Emergency Medical Treatment

Special Events and Field Trips

Publicity

IF THE PARTICIPANT IS A MINOR

2025 Camp Cost

You have not completed signup until you have filled out all required fields and pressed the "Submit" button at the bottom of this page.