Youth Camp Registration 2025

YOUTH CAMP REGISTRATION

Dates: June 29th- July 5th Ages: 11-17 Cost: $140 pre-register before June 18th or $160 after June 18th
CAMPER INFORMATION
Birth Date

MonthDayYear
Camper Name

First NameLast Name
Age
Gender

MaleFemale
Shirt Size
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Church Information
Home Church
Pastor's Name
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed any daily medications? If yes, please explain any instructions.
Cell Phone Policy:

In an effort to avoid causing distractions or other issues while allowing campers to focus on building relationships and drawing closer to Jesus, cell phones will be collected at the beginning of camp. Campers will have daily times when phone usage will be allowed. Should the need arise, campers will be able to access their phones in the event of an emergency. If there is an emergent need to contact your camper outside of daily phone usage times, you may do so by contacting the youth director, Rev. Tyler Rutherford, at 423-470-6025.
I acknowledge that I understand the cell phone policy and that unwillingness to follow this policy will result in inability to participate in Cumberland Grove Youth activities.

I understand
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Cumberland Grove Wesleyan Camp, The TN-KY District of the Wesleyan Church, The Wesleyan Church and their designees, employees, or volunteers during camp. In exchange for the acceptance of said camper's participation by Cumberland Grove Wesleyan Camp, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Cumberland Grove Wesleyan Camp, The TN-KY District of the Wesleyan Church, The Wesleyan Church and their designees, employees, or volunteers and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Cumberland Grove Wesleyan Camp, The TN-KY District of the Wesleyan Church, The Wesleyan Church and their designees, employees, or volunteers, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. I understand that there is a risk of being injured that is inherent in all physical and non physical activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical treatment deemed immediately necessary in the event that I cannot be reached for verbal confirmation of consent. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Cumberland Grove Wesleyan Camp, The TN-KY District of the Wesleyan Church, The Wesleyan Church and their designees, employees, or volunteers and its affiliates including Directors, counselors, and other necessary staff to provide the needed emergency first aid treatment prior to the child’s admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation

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.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

YOUTH CAMP REGISTRATION

CAMPER INFORMATION

Cell Phone Policy: