Central Cal Impact Youth

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Camp* This field is required.
High School July 17th - 21st
Middle School July 21st - 25th
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Name* This field is required.
First Name
Last Name
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Gender* This field is required.
Please Select
Please Select
Male
Female
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.
example@example.com
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Student Date of Birth* This field is required.
Date
Year
Month
Day
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Age* This field is required.
8
Parent/Guardian Name* This field is required.
First Name
Last Name
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Parent/Guardian Phone Number* This field is required.
Please enter a valid phone number.
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Emergency Information: In the case of an emergency, PCG Central Cal Youth Ministries will contact the parent or legal guardian immediately. If we are unable to reach you, please list a secondary contact person who we can call. This contact person must be someone not living in the same household.
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Emergency Contact Name* This field is required.
First Name
Last Name
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Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
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Relationship to Student* This field is required.
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Names of authorized people who can pick up student in case of emergency. * This field is required.
15
Does student have Asthma* This field is required.
YESNO
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Is Student Lactose Intolerant* This field is required.
YESNO
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Allergies (Food, Animals, Insects etc)* This field is required.
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Medical Conditions* This field is required.
Heart defect/disease
Convulsions
Diabetes
Bleeding/Clotting
None of these
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Other Medical Conditions* This field is required.
Yes
No
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Immunizations Current?* This field is required.
Yes
No
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Date of last Tetanus Shot* This field is required.
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Physical Limitations* This field is required.
Yes
No
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Mental Limitations* This field is required.
Yes
No
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Are there activities from which this camper should be restricted?* This field is required.
Yes
No
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Impact Youth Ministries Summer Camp Medication Administer Form:**MEDICATIONS MUST BE SENT IN THE ORIGINAL PHARMACY CONTAINER***
The health and well-being of the above-named student is dependent upon the administration of medicine during the Sequoia Heights visit by its Head Nurse as follows:
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Medications (See Medication Policy)* This field is required.
Yes
No
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Upon arrival, each camper will be checked for head lice. If nits or lice are present, campers will be turned away with no refunds.
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I agree that I will not attend Impact Summer Camp if I experience the following symptoms: Fever: Cough: Shortness of breath of have difficulty breathing: Chills: Muscle Pain or body aches: onset of headaches or sore throat: Nausea and/or vomiting: Loss of taste or smell: Onset of fatigue: GI upset or diarrhea. * This field is required.
Yes
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We agree to mutual sharing of information by our doctor and the Sequoia Heights Staff about our child's needs for the medication. We agree to hold the District Organization, the Sequoia Heights Campgrounds, the Pentecostal Church of God, or any of its District Board or its representatives faultless for any reactions resulting from the administration of the medication child which may occur to our child. We also agree to Immediately notify Impact Youth Ministries in writing of any change in medicine, dosage, and frequency recommended by the doctor.* This field is required.
Yes
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I hereby authorize the PCG, Central Cal Youth ministries and/or its representative, as agent for myself to procure medical, hospital or dental care for my child named on this form, in the event of injury or illness while the child is in the care of the above named, I understand that I am financially responsible for any care procured. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required. But is given to proved authority on the part of my agent to consent to such medical care, should it become necessary. I agree to the medical release* This field is required.
Yes
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I hereby waive any and all claim(s) against the Sequoia Heights Camp Grounds, the Pentecostal Church of God, Central California District (incorporated) or its representatives of any injury or damage that may be incurred to my child, in connection with or incident to Youth Camp. I also authorize designated medical professionals to dispense over-the-counter medications as needed to the camper listed above. I agree to the medical release above.* This field is required.
Yes
32
I understand that participating in youth camp may involve an increased risk of injury or complications to campers with existing medical conditions (such as pregnancy). In consideration of the camper named below being permitted to attend Youth Camp, I waive all claims against the Sequoia Heights Camp Grounds, the Pentecostal Church of God (Incorporated ), referred to below as the "District", arising out of or in connection with the campers participation in Youth Camp and any of its activities. I agree to the supplemental waiver and release from liability above.* This field is required.
Yes
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Further on behalf of both the undersigned and the camper named below, and our respective heirs, legatees, personal representatives and assigns, I hereby discharge, release and hold harmless the District and its affiliates, agents, employees, assigns, officers, directors and successors, from any and all claims, actions, losses, damages, or expenses for personal or bodily injury (including death), and all property loss or damage, incurred by the camper named below (and if pregnant her unborn child) arising out of or in connection with the campers participation in Youth Camp. I agree to the supplemental waiver and release from liability above.* This field is required.
Yes
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I hereby assume and accept full risk and responsibility for all injury, death, property loss or damage which may occur through or by reason of the campers participation in youth camp and any of its activities. I certify to the district that I am the parent or legal guardian of the camper named below. I have consulted with the campers physician and have been advised that the camper’s participation in Youth Camp does not pose any substantial risk despite the camper’s existing medical condition(s). I agree to the supplemental waiver and release from liability above.* This field is required.
Yes
35
Applicants Consent - * This field is required.Applicants Agreement Consent
Yes
36
1. Campers MUST attend ALL scheduled or special called functions. 2. No one is allowed to leave the camp grounds unless authorized by the camp director. 3. All cars will remain parked in designated areas until camp is over. Infraction of this rule will result in keys taken by the camp director. 4. Any camper damaging property will be held responsible and charged for the damages. 5. Any camper leaving their dorm without permission after "lights out" may be expelled from the camp if deemed necessary. 6. All camper medication must be checked into the nurse prior to the start of camp. No medication will be kept in the cabin area. I agree to the camp rules and procedures above.* This field is required.
Parent/Guardian: I agree
Student: I agree
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7. Absolutely no WEAPONS, SMOKING, ALCOHOL, DRUGS, OR VULGAR LANGUAGE will be tolerated during camp. 8. All campers MUST have on file in the registration office proper registration and medical release forms. All information will be kept confidential. 9. Any camper participating in Paintball events must have a signed Paintball Release Form. (Cost is $5 for 100 balls, includes equipment) -Can bring own equipment, but it must be checked in the office & Cannot use their own paintball. 10. Any Camper participating on the Zipline or other High Risk Activities must have waiver signed. I agree to the camp rules and procedures above.* This field is required.
Parent/Guardian: I agree
Student: I agree
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11. Dress Code for PCG Central California Youth Camps. a. Shoes MUST be worn at all times. b. Sleeveless attire or Tank Tops are allowed but straps must be at least 1-1/2 inches in width. c. Any immodest apparel is not allowed; Your upper torso & stomach areas must be covered. d. Mini-skirts, dresses, or shorts which are more than four (4) inches above the knee MAY NOT be worn at any time. 12. All campers will be in subjection to all rules while attending camp. Any infraction of the rules is punishable by expulsion from the camp, if the camp director deems necessary. Parents will be called to escort the camper home. NO REFUNDS AFTER CAMP I agree to the camp rules and procedures above.* This field is required.
Parent/Guardian: I agree
Student: I agree
39
1. The risk of injury from the activity and weaponry involved in paintball is significant, including the potential for permanent disability and death, and while particular protective equipment and personal discipline will minimize this risk, the risk of serious injury does exist; 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE of those persons released from liability below, and assume full responsibility for my participation.* This field is required.
I agree
I do NOT agree
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3. I understand that the activities of paintball are physically and mentally intense. I understand the rules of play and will comply with all rules and regulations. If I observe any unusual or unnecessary hazard during my participation, I will bring such to the attention of the nearest official as soon as practical; and, 4. I understand and agree that this Release of Liability Agreement covers each and every paintball activity and event in which I participate hereafter.* This field is required.
I agree
I do NOT agree
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5. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS FROM LIABILITY THE PENTECOSTAL CHURCH OF GOD AND Sequoia Heights Camp Grounds, the owners and lessors of premises used to conduct the paintball activities, their officers, officials, agents and/or employees or volunteers (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the “Releasees.”* This field is required.
I agree
I do NOT agree
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I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.* This field is required.
I agree
I do NOT agree
43
I maintain and certify that I am, and/or my child is, in good physical and mental condition. And to participate in the zip line and high-risk activities, must not be pregnant or have a history of back or neck injuries, he/she must weigh between 65 and 225 pounds to use the zip line, and I acknowledge that I have voluntarily applied to participate in any of the high risk activities.* This field is required.
Yes
No
44
I am aware that participation in and use of the zip line and other high-risk activities involves inherent hazards and risks, such as but not limited to physical exertion, fast movement at great heights, and slipping or striking the zip line elements. Although use of a helmet is required, such use does not negate such risks. I am also aware that if I am pregnant, have any of the health conditions, injuries, or history of injuries specified above, or if I fall outside of the minimum or maximum weight requirements, that I should not participate in this activity.* This field is required.
Yes
No
45
I further understand that in addition to the above-mentioned risks, there are unpredictable dangers involved in this type of activity. Although many before you have participated unscathed, severe injury is possible.* This field is required.
Yes
No
46
In consideration of my or my child’s participation in this activity, I voluntarily release and agree to indemnify, protect, defend and hold harmless the Sequoia Heights Camp Grounds, Pentecostal Church of God, or any of its District Board, or its representatives, their officers, agents, employees and volunteers from any and all liability for injuries or death, or property damage resulting from or in any way connected with my or my child’s participation in this activity.* This field is required.
I agree
I do NOT agree
47
I understand that this waiver and release is applicable even though the negligent activities of the Sequoia Heights Camp Grounds, Pentecostal Church of God, or any of its District Board, or its representatives, the sponsors, or their officers, agents, employees or volunteers may have caused or contributed to the injury or death or property damage, and this document is binding on my heirs and dependents as well as myself.* This field is required.
I agree
I do NOT agree
48
I freely and voluntarily expressly assume all the risks of participating in this activity. I further agree that if I and/or my child cannot adhere to the rules of participation for this activity, staff shall have the right to ask me to leave and/or discontinue participation in the activity, without refund.* This field is required.
I agree
I do NOT agree
49
Zipline: Consent to Medical Treatment: I authorize staff to render first aid and/or call upon Emergency Medical Services, if needed, for my and/or my child’s well-being.* This field is required.
I agree
I do NOT agree
50
Authorization for use of Image and Content: I understand that during my participation in this activity, I or my child may be photographed. I agree to allow photo, video or film likeness of me to be used for any legitimate purpose by the program officials, producers, sponsors, organizers or assigns, including marketing purposes. Lastly, I agree to accept and abide by the rules and regulations of the zip line and Pentecostal Church of God, or any of its District Board, or its representatives.* This field is required.
I agree
I do NOT agree
51
If participant is not yet of legal age, this Waiver and Release of Liability must be read and agreed to by his/her parent or legal guardian. This waiver expires three (3) months from date of original signature. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND IT AND SIGN IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT.* This field is required.
I agree
I do NOT agree
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Signature of Parent/Guardian: (Your typed name will serve as signature.)* This field is required.
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Name of Subscriber* This field is required.
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Name of Insurance
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Insurance policy Number
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Name & number of Physician
57
Group Number
58
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