SIMC Summer Camps - June 16-20 & June 23-27

Southwest Indian Ministries is a ministry of World Gospel Mission.

14202 N 73rd Ave., Peoria, AZ 8538

If there is a required field on this form that does not apply to you, please type "N / A".

Which camp are you registering for?

High School - Ages 15 to 17 - June 16 to 20, 2025Jr. High - Ages 12 to 14 - June 23 to 27, 2025

Camper's First and Last Name*

Male or Female?

Have you attended camp before

Adult Tshirt size

Current Age

Date of Birth*

Date

Parent/Guardian Text # (In case we need to contact you.)*

Parent/Guardian Email (In case we need to contact you.)*

example@example.com

Mailing Address*

City*

State*

Zip*

Parent/Guardian First & Last Names*

Name of church you attend

Pastor's Name

Name of friend(s) you're coming with or bringing:

Names of all people who have permission to pick your child up from camp*

Permission to Participate in Activities and Events

As the parent or legal guardian of the camper named on this form, I hereby give full permission for my child to participate in all activities and events organized or sponsored by Arizona NYI and the Arizona District Church of the Nazarene (AZNYI), Southwest Indian Ministry Camps (SIMC), and PineRock Camp & Retreat Center. These activities may include, but are not limited to, recreation, swimming, classroom instruction, camp games, ropes courses, off-site trips, and special event excursions.

I understand that some of these activities may take place away from the primary event or camp location. I grant permission for my child to be transported by foot, vehicle, or other means as necessary by authorized staff or volunteers of the above-mentioned organizations.

I acknowledge that I have read and understood the risks and expectations outlined in the general waiver and release of liability provided by these organizations, and I consent to my child’s participation in all scheduled and supervised activities.

Parent/Guardian Signature*

Date*

Date

Photo and Media Release Agreement

As the parent or legal guardian, I hereby grant permission for Southwest Indian Ministry Camps (SIMC), World Gospel Mission (WGM), AZNYI, and the Arizona District Church of the Nazarene to photograph, record, or otherwise capture the image, likeness, or voice of my child while participating in events, activities, or while on church or ministry property. I authorize these organizations to use such images, likenesses, or recordings in print and digital publications, promotional materials, video presentations, websites, and social media platforms.

I understand that this consent is given voluntarily and without expectation of financial compensation. I further release SIMC, WGM, AZNYI, and the Arizona District Church of the Nazarene from any legal liability or claims associated with the use of these photographs, recordings, or likenesses. This permission is granted of my own free will and may be revoked in writing at any time.

ParentGuardian Signature*

Date*

Date

Choose one:*

I will be dropping off and picking up my child at the Christian community center (formally known as the SW. Indian Ministries Center) 14202 N. 73rd Ave., Peoria, AZ 85381.I (or someone else) will be dropping off and picking up my child at camp Pinerock 1400 Pine Dr., Prescott, AZ 86303.

Medical Consent and Financial Responsibility Agreement

I hereby give permission for my child to receive first aid treatment if deemed advisable by the staff of either the Southwest Indian Ministry Camps (SIMC) or Arizona NYI (AZNYI). In the event of illness or injury occurring to my child while participating in any SIMC or AZNYI travel or activity, and in the event I cannot be reached, I authorize the Lead Staff of SIMC or the attending staff of AZNYI to consent to any medical, dental, or surgical examination, diagnosis, treatment, anesthetic, or hospital care that is deemed necessary and rendered under the general or special supervision of a licensed physician, surgeon, or dentist, as permitted under the applicable Medical or Dental Practice Acts. I understand that such care may include diagnostic procedures such as lab work or x-rays. I acknowledge that reasonable efforts will be made to contact me in the case of other than minor illness or injury. I further agree to assume full financial responsibility for any medical, dental, ambulance, or related health care expenses or transportation home resulting from such illness or injury, regardless of whether my child has valid health insurance or ACCHS coverage.

Insurance Company*

Member ID:*

Group #:*

ParentGuardian Signature*

Date*

Date

MEDICAL IINFORMATION AND PERMISSION TO GIVE MEDICATION

Does your child have any allergies? If yes, please list them below and what happens when exposed.*

YesNo

FOODS: What foods is your child allergic to and what happens if he or she eats them?*

MEDICATIONS: Please list any medications your child is allergic to:*

SEASONAL ALLERGIES:*

BEE STINGS OR OTHER INSECT BITES:*

PLEASE LIST ANY MEDICAL CONDITIONS OR RECENT ILLNESSES THAT WE NEED TO BE AWARE OF:*

MEDICATIONS:

ALL MEDICATIONS MUST BE TURNED IN DURING REGISTRATION.

Prescription Medications must be in the original container from the Pharmacy with the Dr.'s name and directions clearly visible on the label. Please list the Prescription and Over The Counter Medications your child has with him/her and needs to take during camp along with the instructions for giving them.

Please list Name of Medication / Dosage and Time / Reason for taking:

In addition to the medications listed above, I give permission for SIMC staff to give the following medications (that I have marked below) to my child as needed, according to the appropriate age/weight dosing:

Other medications ok to give if needed:

Cough Drops or Cough Syrup (Guaifenesin)Tylenol (for pain or fever)Calamine Lotion for itchIbuprofen (for pain or fever)Bacitracin or other antibiotic ointment for wound care/infection preventionMaalox for upset stomach

Parent/Guardian Signature*

Date*

Date

Make non-refundable $110 check payable to "World Gospel Mission"
and mail to 14202 N 39th Ave., Peoria, AZ 85381 before Friday, May 30, 2025.

or Go to https://www.SIMcamps.com/camp and pay $110 online.

Medical Release & Consent Forms for AZNYI TRIPS & ACTIVITIES

Most information will be pulled from the SIMC Camp Registration.

Camper's Grade for the 2025-26 school year*

Camper's Cell Phone number*

Please list someone NOT participating in this trip Emergency Contact - Full Name: Emergency Contact - Relationship to camper:

Emergency Contact - Cell Phone Number: *

Emergency Contact: Full Name:*

Emergency Contact: Relationship to camper:*

Emergency Contact: Email:*

example@example.com

Doctor's First and Last Name

Doctor's Contact Phone Number

Acknowledgment of Risk and Release of Liability

I understand and acknowledge that participation in any event, camp, or activity organized by Arizona NYI and the Arizona District Church of the Nazarene (AZNYI), PineRock Camp & Retreat Center (PineRock), and Southwest Indian Ministry Camps (SIMC) involves inherent risks. These risks may include, but are not limited to: exposure to infectious or communicable diseases, sickness, emotional distress, bodily injury, property damage, financial loss, or death. Activities may include but are not limited to: archery, climbing wall, low ropes, high ropes, zip line, paintball, BB guns, swimming, group games, hiking, transportation to and from events, and other camp- or event-related activities.

With full knowledge of my child’s physical condition, capabilities, and limitations, I voluntarily assume all responsibility and risk of loss, damage, illness, injury, and/or death that may occur during participation in any such activities or in transit to and from those activities. I accept personal financial responsibility for any such injury or loss, including medical or emergency expenses incurred.

I hereby release, indemnify, and hold harmless AZNYI, the Arizona District Church of the Nazarene, PineRock Camp & Retreat Center, World Gospel Mission, Southwest Indian Ministry Camps (SIMC), and all their affiliated agents, employees, volunteers, staff, officers, and representatives from any claim or liability, whether arising from negligence or otherwise, connected in any way to participation in any of the described activities. I agree not to initiate a claim or legal action against any of the above organizations or individuals for any loss, injury, or damages (including death) arising from my child's participation.

I understand that every reasonable precaution has been taken to ensure the safety of each participant. I agree to abide by all rules, regulations, and behavioral expectations set by these organizations, and I understand that failure to do so may result in my child’s removal from the activity.

In the event of a dispute that cannot be resolved informally, I agree to pursue a mutually acceptable alternative dispute resolution process. If no agreement can be reached, I consent to submit any dispute to a three-member arbitration panel in accordance with the rules of the American Arbitration Association.

I certify that I have read and fully understand this agreement, waiver, and release. I sign it voluntarily and with full knowledge of its legal significance, and I do so on behalf of my minor child and myself.

Signature

Camper's Signature:*

Date of camper signature*

Date

SIMC Camps

PARTICIPANT AGREEMENT, WAIVER AND RELEASE