2024 Camp Chaperone

TEEN CAMP CHAPERONE FORM

Chaperones MUST have Naz Safe training and background check to attend.

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 Chaperone Registration
Chaperone Information
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Emergency Contact Name*

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

MaleFemale
T-shirt Size*

SmallMediumLargeX-Large2X-Large3X-Large4X-Large
Church You Attend*

Insurance & Medical Information
Please list any medical problems. If none, type NA.*

Naz Safe training and a background check are a requirement to attend camp. Contact Ben Johnson for questions.
Have you completed Naz Safe training?*

YesNo
Have you had a background check within the last two years?*

YesNo

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 participation with CPV (Camp Paradise 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 WHILE PARTICIPATING OR ATTENDING “CGC”, 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 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 with CPV on or off its premises, 2) this Agreement and/or 3) the Participants with any activity offered through or by CPV, such claims to be brought in the Kentucky courts. By signing this, I understand that this Agreement supersedes any oral or written expressions between CGC and the participation with its activities.

Signature

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.
Name*

First NameLast Name
Should be Empty:

Teen Camp Chaperone Registration

Chaperone Information

Insurance & Medical Information

Naz Safe training and a background check are a requirement to attend camp. Contact Ben Johnson for questions.

Rules & Liability

Signature