SIMC Teen Camp - September 19-21, 2025

Southwest Indian Ministries Camps

A Ministry of World Gospel Mission

14202 N 73rd Ave

Peoria, AZ 85381

Age 13 to 18 Camp September 19-21, 2025

*Please read the entire form carefully.

Camper's First & Last Name*

Male M or Female F*

Have you attended camp before?

Camper's T-shirt size (adult sizes only) additional $10*

Current Age*

Camper's Date of Birth*

Date

Grade Level for 2025-26 School Year*

We must have a way to contact you. Please provide a number to text or an email. Preferably both. If you don't have a cell phone or an email, type "N/A" in the fields below.

Text #*

Email*

example@example.com

Street Mailing Address*

City*

State*

Zip*

Parent/Guardian's Name(s)*

Name of church you attend

Pastor's Name

Name of friend you're coming with or bringing

Names of all people who have permission to pick your child up from camp*

Name of Medical Insurance Provider*

Policy number*

Group number*

ALLERGIES: Does your child have any known allergies?*

YesNo

If yes, please input "yes" and give further explanations.

If no, please input "N/A"

FOODS What foods is your child allergic to and what happens if he or she eats them*

MEDICATIONS Please list any medications your child is allergic to*

SEASONAL ALLERGIES*

BEE STINGS OR OTHER INSECT BITES*

PLEASE LIST ANY MEDICAL CONDITIONS OR RECENT ILLNESSES THAT WE NEED TO BE AWARE OF*

As the Parent/Guardian of the camper listed above, I hereby give permission and consent as follows:

Activity Participation
I give permission for my child to take part in all activities of SIMC Camp, including but not limited to recreation, field trips, swimming, and classroom instruction.

Photo/Media Release
I consent to the use of my child's photograph, likeness, voice, or image, whether in still, video, or audio format, by World Gospel Mission/American Indian Field/Southwest Indian Ministry Center (SIMC) for publications, promotional brochures, video presentations, websites, and display formats. I understand I am granting this permission without any financial compensation and release World Gospel Mission/American Indian Field/SIMC from any legal liability arising from such use. I give this consent of my own free will.

Medical Treatment Authorization
I authorize SIMC staff to administer first aid to my child if needed. In the event of a medical emergency and if I cannot be reached, I authorize the Lead Staff at SIMC to consent to any examination, x-ray, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care considered necessary and to be rendered under the general or special supervision of any licensed physician, surgeon, or dentist. I agree to assume financial responsibility for any medical costs incurred if my child requires medical treatment and does not have valid insurance or AHCCCS coverage.

Medications
I agree that all medications (prescription and over-the-counter) my child brings to camp will be turned in at registration, in original containers with clear pharmacy labeling as required. Below is a list of my child's medications and instructions for administration:

Name of Medication / Dosage and Time / Reason for taking*

In addition to the medications listed above, I give permission for SIMC staff to administer the following over- the-counter medications to my child as needed, according to appropriate age/weight dosing (please check all that apply):

In addition to the medications listed above, I give permission for SIMC staff to administer the following over-the-counter medications to my child as needed, according to appropriate age/weight dosing (please check all that apply):

Cough Drops or Cough Syrup (Guaifenesin)Ibuprofen (for pain or fever)Maalox (for upset stomach)Tylenol (for [ain or fever)Bacitracin or other antibiotic ointment for wound care / infection preventionCalamine Lotion (for itching)

I acknowledge that I have read and understand this Combined Release and Consent Form and agree to its terms.

ParentGuardian Name printed*

ParentGuardian Signature*

Today's Date*

Date

* Emergency Phone Number*

Make non-refundable $55 check payable to "World Gospel Mission" and mail to

SIMC
14202 N 73rd Ave
Peoria, AZ 85381

before Friday, September 5, 2025. ($65 includes Tshirt)

OR go to https://www.SIMCamps.com/camp and click the 'Pay Online' button.

Cost & Payment Information:

SIMC Camps is a ministry of World Gospel Mission. Camp costs are covered through a combination of donations and camper fees.

The actual cost of a weekend camp is approximately $250 per camper, but thanks to generous supporters, we ask each camper to contribute just $55 to help offset expenses.

We never want finances to prevent a child from attending camp. If your family is unable to pay the full $55, we invite you to give a donation that fits your situation - every bit helps.

If you're able and would like to sponsor another camper, you're welcome to give more than the suggested amount.

Thank you for your understanding and support!

To make a payment, visit https://www.SIMcamps.com/camp and click the Pay Online button under your camp.

Camper Expectations:

At SIMC Camp, all campers are expected to participate fully in worship, discussions, and activities so we can learn, grow, and have fun together.

Campers should treat everyone with respect, follow instructions from leaders, stay with their group, and help keep our camp clean and safe. Personal electronics should be put away during organized activities so we can focus on God and each other.

Above all - have fun and participate!

I agree to follow all the camp expectations. (Camper's Signature)*

PARTICIPANT AGREEMENT, WAIVER AND RELEASE

Knowing there are dangers, hazards, and risks associated with Pinerock Camp & Retreat Center's activities including Archery, Climbing Wall, Low Ropes, High Ropes, Zip Line, Paintball, BB Guns, Swimming Pool, and/or related activities (hereafter "Activities"), and with sufficient knowledge of my experience, physical condition, and any and all limitations I may have at the time, I voluntarily assume all responsibility and risk of loss, damage, illness, injury and/or death that I may in any way sustain in connection with my voluntary participation in any and/or all of these Activities.

Understanding that I could be injured or die as a result of my participation in the Activities, I agree to release, indemnify and discharge Pinerock Camp & Retreat Center and their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (collectively "Pinerock") and hold Pinerock harmless on behalf of myself, my children, my parents, my heirs, assignees, personal representative and estate.

It is my intent by signing this document to agree not to make a claim or bring a law suit against Pinerock and to forever release them from any and all legal responsibility for any loss, injury, damage (including death) that I may suffer as a result of my participation in the aforementioned Activities whether due to negligence, default, action or inaction on the part of Pinerock.

Upon signing this form, I acknowledge and agree that I must abide by all rules, regulations, expectations, and standards of conduct applicable to participation in the Activities. I understand that Pinerock reserves the right to limit or terminate my participation in any activity, in the sole discretion of Pinerock staff.

I also herby grant Pinerock Camp & Retreat Center permission to use my likeness, which may appear randomly and without any intent to exploit me personally, in any photograph, video, or other digital media captured in the normal course of Pinerock's memorialization of activities at the camp, in any and all of its publications, including web-based publications, without payment or other consideration given to me.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT, WAIVER AND RELEASE AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Camper's Name*

Camper's Signature

Today's Date

Date

Name of Emergency Contact*

Emergency Contact's Phone #*

Emergency Contact's Relationship to Camper*

PARENT/GUARDIAN CONSENT (to be completed if the participant is under the age of 18)

I herby consent that my child may participate in Activities. I have read and fully understand the agreement, Waiver and Release and consent on behalf of the Participant to its terms.

Parent/Guardian Name*

Relationship to Camper*

Parent/Guardian Signature*

Today's Date

Date

SIMC

SIMC CAMP COMBINED RELEASE AND CONSENT FORM