Camp Registration Form

Camper Information

Camper's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Camper Cell #

Camper E-Mail

example@example.com

Birth Date*

MonthDayYear

Grade at time of camp*

Age at time of retreat*

Adult T-Shirt Size*

Gender*

MaleFemale

Name of School

Are you currently part of a youth group in a CCCU church?*

YesNo

Church Name*

Youth Leader's Name

Youth Leader's Phone Number

If your student was invited by a friend to this retreat, place their name here!

Parent/Guardian Information

Parent/Guardian #1*

First NameLast Name

Phone Number*

Alt Phone Number

Parent E-mail*

example@example.com

Parent/Guardian #2

First NameLast Name

Phone Number

Alt Phone Number

CAMPER AGREEMENT

If you checkmark this box, you are promising to attend all activities and services, to obey all the rules of the retreat center and the grounds, and to conduct yourself as a lady/gentleman at all times.

I Agree

Today's Date

Date

MEDICAL INFORMATION
The information below is necessary for the retreat nurse and/or coordinators to adequately treat your child in the event of an injury or illness. All information will remain confidential.

Physician Name*

First NameLast Name

Physician Phone Number*

Insurance Company*

Write N/A if not available

Policy/ID Number*

Write N/A if not available

Is Your Child up to date on all immunizations?*

YesNoOther

Medications your child is currently taking*

Please add in scheduled times and dosage amount. All medications must be turned in to the camp nurse at check-in. Medications must be in their original container with the camper's name and the name of the medication on the bottle.

Allergies*

Is your child able to participate in strenuous activities?*

YesNoOther

Chronic or existing illnesses (mental health included) and other needed health information.*

What else shoud counselors know about your child? *

Emergency Contact #1 Name*

First NameLast Name

Relationship*

Phone Number*

Emergency Contact #2 Name*

First NameLast Name

Relationship*

Phone Number*

PARENT OR GUARDIAN RELEASE

I understand that my child is under the supervision of quality leadership while attending camp. However, I also understand that my child will be participating in activities that could cause possible injuries, such as swimming, sports, boating, tubing and construction projects. I understand that great care is taken to ensure the safety of my child but that some of the activities may be dangerous by nature. Therefore; I release the camp and its governing board(s) as liable or responsible for injuries in the event of a lawsuit. I also give permission for my child to be transported off campgrounds for participation in camp activities. Furthermore, I authorize the Camp Coordinator, Assistant Coordinator, Camp Nurse, or any other official they deem appropriate to seek any necessary examination, treatment and/or hospital care for the camper named above under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the State of Ohio. I grant permission for photographs to be taken of my child for camp directories and for publicity use.

I, as a parent or guardian, agree with the above statement.*

Yes

I, as a parent or guardian, agree to allow camp staff to take pictures of my child for social media updates & various Evangelical Christian Youth promotions.*

YesNoOther

RETREAT PAYMENT INFORMATION

Please share in detail the person or church that will be paying for this student's fee.*

Write N/A if payment will be made through a scholarship fund or no payment is being made due to a waived fee.

If paying for multiple retreat fees, please place each student's name here.

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. I ACKNOWLEDGE THAT ALL OF THE ABOVE INFORMATION IS TRUE.

Signature*

----------------*

First NameLast Name

PLEASE MAKE PAYMENT ONLINE OR SEND CHECKS PAYABLE TO "CCCU" WITH YOUR STUDENT'S NAME AND "FALL RETREAT" WRITTEN ON THE MEMO LINE.

Send checks to:
CCCU ECY
1553 Lancaster Pk
Circleville, OH

My Products

FALL RETREAT-FULL PAYMENT

$125.00 Quantity

FALL RETREAT-HALF PAYMENTOnly for students who have applied and been awarded a half scholarship, or their church has offered to pay half

$62.50 Quantity

Sending a Check *ECY and CCCU staff will verify that a check was received

$ Free Quantity

Total

$0.00

2025 Fall Retreat Registration