Clone of RevTabYouthCamp Registration Form 2025

Registration Details: Camper and CIT Registrations include a camp t-shirt and a $10 canteen card.

$25 Non-Refundable deposit due at time of registration.
- Camper Early Registration : $225 (ends June 21st)
- Camper Registration: $275
- CIT Early Registration: $175 (ends June 21st)
- CIT Registration: $225
- Payment method: Cash, Check, Credit Card, Apple Pay, and Google Pay accepted. Please make the check payable to RevTab Youth Camp and write your child's full name on the memo line.
All Staff must submit current (within 5 years) background clearances to revtabyouthcamp@gmail.com.

Contact: For more information, please contact Donna Wenrick at revtabyouthcamp@gmail.com or leave a message at 570-538-2000, Ext. 100.
CIT (Counselor-in-Training) Program: designed to help train, prepare and transition experienced campers into future counselors and/or staff.

1. Must be entering senior year of high school or have just graduated. (If CIT is 17, a parent must sign this application)

2. Must have at least one year's experience as a Camper at RevTab Youth Camp.

3. Must obtain their Pastor's recommendation.

4. Be exemplary in attitude/behavior always. CIT's will be responsible to Deans & Senior Counselors

5. CIT will be assigned to a Senior Counselor or staff, serving as an aide in fulfilling assigned duties. This responsibility will be daily, but limited to certain times. The remainder of the time, CIT's will function as a typical Camper.

Parent/Guardian's Name:

First NameLast Name
Parent/Guardian's Address:*

Street Address

Street Address Line 2

CityState

Postal Code
Parent/Guardian's Cell Number:*
Format: (000) 000-0000.
Parent/Guardian's Email:*
example@example.com
YesNoN/A
Pastor's Name:

First NameLast Name
YesNo
Pastor's Phone Number:
Format: (000) 000-0000.
Home Church:
Emergency Contact (other than the parent above)

In case we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent above).
Emergency Contact's Name:*

First NameLast Name
Emergency Contact's Number:*
Format: (000) 000-0000.
Relationship to Applicant:*

KitchenCanteenRecreationMaintenanceAssist CounselorsNo PreferenceN/A - Applicant is not a CIT(Counselor In Training)Other

Medical Information

Please fill out all fields with an asterisk.
Applicant's Name:*

First NameLast Name
Parent/Legal Guardian's Name:*
Parent/Legal Guardian's Phone Number:*
Emergency Contact's Name:*
Emergency Contact's Phone Number:*
Format: (000) 000-0000.
Health Insurance Company*
Policy Number
Physician's Name:*
Physician's Phone Number:*
Please list any dietary restrictions and food allergies:
Please list all known medical condition(s):
YesNo
YesNo
Medications:
Date of last tetanus:
MM/DD/YYYY
Is there any other information about the participant that you should disclose in order to protect them, or other's health, safety, comfort, or wellbeing? If so please specify:

PLEASE READ BEFORE SIGNING

Agreement to Participate

The proposed activities provided by RevTab Youth Camp require participation in physical exercises which are, by their nature, physically demanding. If there is any doubt about your child's ability to safely participate in any physical activity at youth camp, please seek and provide authorization from their medical provider. It is solely your responsibility to receive the necessary approval from the appropriate health care providers for your child's participation in all physical activities. If more information is needed, please contact RevTab Youth Camp, at (570) 538-2000 or email us at revtabyouthcamp@gmail.com.

Assumption of Risk and Release of Liability

Activities at RevTab Youth Camp may result in loss or damage to personal property, physical injury, or fatality due to accident. My authorization below indicates that my child is healthy (both physically and emotionally) and capable of participating in RevTab Youth Camp. The person herein described has permission to engage in all prescribed activities unless otherwise noted. I fully authorize the camp’s medical personnel to treat my child. I do hereby release Revival Tabernacle, Inc., it's affiliates including RevTab Youth Camp and its employees from any and all liability, including, but not limited to, any negligence of the aforementioned. I also understand that my child's participation is entirely voluntary. I take full responsibility for my child to participate or not participate and agree that they will follow all safety instructions. My e-signature below should be considered the authorization to both the Agreement to Participate and the Assumption of Release and Liability.
Yes
Yes
Applicant's Name:*

First NameLast Name
E-Signature of Parent/Guardian if under 18 years of age:

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*Camper and CIT registrations include a camp t-shirt and a $10 canteen card

Camper and CIT Early Registration ends June 21st

Extra Camp T-Shirt: $13

Additional Canteen Cards can be pre-purchased in $5 increments.

Registration Fee:*

USDTotal

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Emergency Contact (other than the parent above)

Medical Information

Payment Methods