2025 Camper Form

TEEN CAMPER FORM

LOCATION: Camp Paradise Valley, Burkesville, KY

DATES: July 28 - August 1, 2025

PRICE: $300 per person (same price for chaperones & campers)

REGISTRATION: 1:00-3:00

SPEAKERS: Dave Dorn, Trevor Ford, & Eric Smith

WORSHIP: Albany United

REGISTRATION & MONEY DUE: July 13th (Maily check to Kelly Crawhorn. Reminder that there are no refunds for dropped campers)

NOTARIZED FORMS DUE: Upon arrival

Teen Camp Student Registration
Camper Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Grade Most Recently Completed*
Camper Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camper Cell Phone
Please enter a valid phone number.
Parent/Guardian Cell Phone*
Please enter a valid phone number.
Parent/Guardian Work Phone*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Emergency Contact Name Other Than Parent*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Gender*

MaleFemale
T-shirt Size*

SmallMediumLargeX-Large2X-Large3X-Large4X-Large
Expected Year of High School Graduation*
Church You Attend*
Youth Leader Email*

Insurance & Medical Information
Please list any medical problems. If none, type NA.*
Allergies*
Past Surgeries*
OTC Medicines Which CAN be Administered*

TylenolIbuprofenAntihistamineTumsSwimmer's EarNoneOther
Medications you are allergic to *
Insurance Company*
Policy Number*

Rules & Liability
Medical & Liability Release

I assume and accept full, complete, and sole financial responsibility for any and all costs and expenses that may arise from any and all medical care received by the participant during the camper’s participation with CPV (Camp Pardise Valley). “Medical care” is given it's broadest interpretation and includes, but is not limited to, ambulance, transportation, rescue, evacuation, testing, x-rays, and other diagnostic imaging, diagnosis, and treatment.
Release of All Claims, Covenant Not to Sue, and Indemnity Agreement

I hereby release, discharge, waive and promise not to sue “CPV and/or KY District Church of the Nazarene and/or their respective directors, staff, volunteers, administrators, and/or other participants, owners and lessees of the premises where CPV/KY Teen Camp is conducted or off-camp activities are conducted (collectively “RELEASES”, FROM /FOR ANY AND ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DEMANDS CAUSED OR ALLEGED ARISING FROM OR RELATED TO ANY AND ALL MEDICAL CARE RECEIVED BY THE CAMPER WHILE PARTICIPATING OR ATTENDING “CPV”, INCLUDING ANY AND ALL CLAIMS ALLEGED FOR EMOTIONAL DISTRESS and/or CLAIMS ARISING FROM NEGLIGENT RESCUE AND/OR EMERGENCY RESPONSE OPERATIONS. I FURTHER AGREE THAT IF DESPITE THIS RELEASE, I, THE CAMPER/ PARTICIPANT OR ANYONE ON THE PARTICIPANT’S BEHALF MAKES A CLAIM ARISING FROM ANY INJURY (INCLUDING DEATH), LOSS AND/OR DAMAGE EXPERIENCED BY ME OR THE PARTICIPANT ARISING FROM THE MEDICAL CARE PROVIDED TO THE PARTICIPANT / CAMPER, I AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS EACH AND ALL THE RELEASES FROM ANY AND ALL LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY DAMAGES, AND/OR OTHER COSTS THAT MAY OCCUR AS A RESULT OF ANY SUCH CLAIM.
Forum Selection & Choice of Law

I agree that in the event that any claim or dispute of any nature arises out of or relating to 1) the Participant / Camper with CPV on or off its premises, 2) this Agreement and/or 3) the Participants/Campers with any activity offered through or by CPV, such claims to be brought in the Kentucky courts. By signing this on behalf of a Minor Participant, I understand that myself and the Minor Participant as set out above that this Agreement supersedes any oral or written expressions between CPV and the participation with its activities.

Signatures

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Student Signature*

First NameLast Name
Parent Signature*

First NameLast Name

Notarized Forms

Download the medical release form from the NYI website, have it notarized, and return to your youth leader. They will bring a copy to camp when you come.
Should be Empty:

Teen Camp Student Registration

Insurance & Medical Information

Rules & Liability

Signatures

Notarized Forms