2026 Teen Reach Adventure Camp - Camper Application

TEEN REACH ADVENTURE CAMP 2026 - Camper Application

King's Harbor Church
Camper*

Camper's First NameCamper's Last Name
Boys Camp Dates:
Friday, August 7, 2026-Sunday, August 9, 2026

Girls Camp Dates:
Friday, August 14, 2026-Sunday, August 16, 2026

Camper Ages:
We accept applications for campers who are 12-15 years of age at the start date of camp.

Camp Sponsoring Church:
King's Harbor Church
23915 Garnier Street
Torrance, CA 90505

Camp Directors:
Erika & Drew Hettinger and Paula Gooch

Contact Information:
1(310)376-6555 ext. 144
trac@kingsharbor.org

Instructions:
This form must be completely filled out. The information is vital to the health and well-being of your child. Your application will not be valid if it is not filled out completely.

Submission of this application does not guarantee your child's reservation for Teen Reach Adventure Camp 2026. You will be notified at the beginning of June if we are able to accommodate your child for camp this summer.
SECTION 1. Camper Information
Camper*

Camper's First NameCamper's Last Name
Camper’s preferred name. This will be put on their nametag and we will call the camper by this name. (For example, their legal name is Thomas but they prefer to be called Tommy or Tom.)*
Camper's Biological sex*
Camper's Birthdate*

MonthDayYear
Confirm Camper's Birthdate*

MonthDayYear
Camper's Age on August 7, 2026*
Does the camper speak English?*
What language(s) does the camper fluently speak?*
Please list Camper's ethnicity:*
Camper is living with (check one):*
1. Name of person Camper is currently living with*

First NameLast Name
1. Relationship to Camper (bio-parent, adoptive/foster parent, relative, etc.)*
1. Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
1. Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
1. Work phone number
Please enter a valid phone number.Format: (000) 000-0000.
1. Email Address (all Camp correspondence will be sent here)*
example@example.com
1. Confirm Email Address*
example@example.com
2. Name of person Camper is currently living with

First NameLast Name
2. Relationship to Camper (bio-parent, adoptive/foster parent, relative, etc.)
2. Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
2. Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState or Province

Postal/Zip Code
Length of time Camper has been in this home*
Names and ages of other foster children living in the home:
Name of Emergency Contact (During Camp)*

First NameLast Name
Relationship to Camper*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address*
example@example.com
Name of Camper's case worker*

First NameLast Name
Case worker's phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Case worker's email address*
example@example.com
Name of case worker's supervisor

First NameLast Name
Supervisor's phone number
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor's email address
example@example.com
Camper's Shoe Size (please indicate child or adult sizes)*
Camper's Shirt Size*
Camper's School*
Camper's Grade*
Currently in foster carePreviously in foster care but now reunited with familyPreviously in foster care but now adoptedYouth of an incarcerated parentOther
Background on Camper's previous placements:*
Explain any family circumstances that make camp especially important for the Camper: (for example: recent crisis, moved foster placements, severe economic needs, etc.)*
Please list names of any individuals who are not safe/not allowed to be around the Camper (i.e. biological parent, former foster parent, bio sibling, etc.)
Has the Camper previously attended Royal Family KIDS Camp?*
If yes, name the city and sponsoring church:*
Has the Camper previously attended Teen Reach Adventure Camp?*
If yes, name the city and sponsoring church:*
Do you give your approval for the camper to attend the 1-year-long post-camp TRAClife Mentoring Program with King's Harbor Church if he/she is selected to be a participant?*
If you would like more info on this program, please contact us at traclife@kingsharbor.org
Angel Tree

We are so excited to continue partnering with Angel Tree, an organization serving children whose biological parents are or have been incarcerated. Please complete the following information so we know if your camper is eligible for additional resources from Angel Tree. At the end of camp, if you give us your permission, we will share the camper's name, your contact info, and the info below with Angel Tree so they can contact eligible campers.
Does the camper have a biological parent currently or previously incarcerated?*
If so, what is the name of the incarcerated parent?*
List the name of last known facility (if known):*
Release date (if applicable):*
Did the camper receive a Christmas gift from their incarcerated parent through Prison Fellowship Angel Tree?*
Does the camper live in the same household as an Angel Tree Child who is also attending camp?*
I give my permission to share this info with Angel Tree:*

SECTION 2. Camper Emotional & Behavioral History

Please help us get to know your camper so we can provide a safe, positive, and supportive camp experience. A history of emotional or behavioral challenges does not disqualify a camper from attending. We ask these questions so our staff can be prepared to best support your youth. Please indicate how often your camper has displayed the following emotional or behavioral concerns in the past 12 months.
Does the Camper receive special educational services at school for learning/social/ emotional issues?*
If yes, please indicate the Camper's diagnosis:*
If yes, please describe details:*
Does/did your child receive psychological therapy now or in the past?*
If yes, please indicate any diagnosis the Camper has received:*
If the Camper is currently receiving psychological therapy, please indicate how often:
Camper's Current Emotional Age
Please name any strengths and positive behaviors your camper might have (good listener, leader, friendly, etc.)*
Please name any interests or hobbies your camper has.*
In the space below, please provide any concerns about your youth's behavior/emotions that would assist us in meeting his/her needs at camp. For example: May easily become angry, moody, or frustrated; May withdraw from group and run away from others; or May experience bed wetting or nightmares/ night terrors.*
Please explain any behaviors that occur often and describe how they are handled.*
Are there any triggers that may upset your camper that we should be aware of? (For example, certain noises, sounds, physical touch, or other environmental factors.)*
Please provide coping skills that helps your camper control their emotions (For example, breathing skills, fidget toys, talking, walking outside, etc.)*

SECTION 5. Medical & Liability Release
MEDICAL RELEASE: This health history is correct so far as I know, and the above-named minor has permission to engage in all prescribed program activities. The undersigned does hereby authorize T.R.A.C., on behalf of the undersigned, to consent to an X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above minor, which is deemed advisable by, and to be rendered under the general or special supervision of any physician/surgeon, licensed under the provision of the Medical Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, at camp or elsewhere. This authorization will remain effective while the above minor is en route to and from or involved in or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Camp Director. During camp, prescription medication will be administered to youth as directed by a physician. T.R.A.C. will do everything in its power to prevent incorrect medication from being given. However, the local T.R.A.C./Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp and King's Harbor Church South Bay, is not liable for incorrect medication provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medication, bottles and dosages at the time of registration. This is not the time to give medication vacations to your teen.

LIABILITY RELEASE: Every precaution will be taken to protect campers and volunteers from harm, but the local T.R.A.C./Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp is not liable for injuries/death that youth or volunteer staff may incur while camping or participating in T.R.A.C. activities. If he/she is injured, I have given medical information and permission to take him/her to a medical facility for proper care. All extension activities are included in the liability release. I release the local T.R.A.C./Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp and King's Harbor Church South Bay, from any liability surrounding any injuries/death to the camper and/or the camper's unborn child if the camper is pregnant.

As legal guardian of the above youth, I agree that all the information provided in this application is accurate. I also agree to both the medical and liability releases and the permission to administer first aid and over-the-counter medications as indicated in Section 5 above.

NOTE: AT CAMP REGISTRATION, MEDICATIONS MUST BE IN ORIGINAL PRESCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. THIS IS NOT THE TIME TO GIVE MEDICATION A VACATION.
YesNo
Camper's health insurance/Medicaid card photo

Cancelof
Signature of Legal Guardian*
Printed Name*
First Name + Last Name
Relationship to Camper*
Signature Date*

MonthDayYear
Date / Mes/Día/Año
NOTE: I certify I am the legal guardian of the above applicant. To be legally binding, I must use a legally binding electronic signature service such as DocuSign OR print, sign in pen, & scan to return.

SECTION 6 - Teen Reach Adventure Camp - CONSENT FORM
COUNSELORS/STAFF: Every effort will be made to contact the camper's camp counselor from Royal Family KIDS Camp so consistency may be achieved from camp-to-camp. However, this is not always possible. All camp counselors and staff at Teen Reach Adventure Camp are interviewed, screened with background checks/fingerprints, and receive training before volunteering on the T.R.A.C. Team.

CONFIDENTIALITY: Every youth registered at T.R.A.C. has the right to confidentiality. Our camp counselors are instructed not to take photos or exchange addresses, phone numbers, email addresses, or social media accounts with any camper. Any photographs or videos obtained by T.R.A.C. will be edited, by blocking out faces, before being used in any promotional materials.

SAFETY: Every precaution will be taken to protect campers and volunteers from harm.

LIABILITY: T.R.A.C. volunteers are aware of our responsibility to keep each youth safe but Teen Reach/Teen Reach Adventure Camp/T.R.A.C. is not liable for injuries/death youth or volunteer staff may incur while at camp or participating in T.R.A.C. activities.

MEDICATION: Each day of T.R.A.C., medication will be administered to youth as directed by their physician. Teen Reach Adventure Camp will do everything in its power to prevent incorrect administration of medications. However, T.R.A.C./Teen Reach is not liable for incorrect medication provided by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for providing the correct medication, bottles and dosages at the time of check-in. THIS IS NOT THE TIME TO GIVE MEDICATION VACATIONS to your youth.

FINANCIAL COMMITMENT: T.R.A.C. is made possible by the volunteer hours and donations committed to running this program. T.R.A.C. is free for the caregivers and campers attending.

PARTICIPATION AGREEMENT: At T.R.A.C., campers and volunteers will participate in activities such as high ropes course, boating, kayaking, swimming, and archery, among other activities.

I acknowledge that participation in Teen Reach Adventure Camp and the activities described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.
In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.
If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.
I have read the above statement and understand that by signing my name below as the legal guardian of

Camper's Full Name* ,
I agree that T.R.A.C. Volunteers will take every precaution to protect
Camper's Full Name*
from harm. However, in any instance the camper is injured, I have given medical information and permission to take the camper to a medical facility for proper care. I release the local T.R.A.C./Teen Reach National and King's Harbor Church South Bay from any liability surrounding injury/death.
Signature of Legal Guardian*
Printed Name*
First Name + Last Name
Relationship to Camper*
Signature Date*

MonthDayYear
Should be Empty:

TEEN REACH ADVENTURE CAMP 2026 - Camper Application

SECTION 1. Camper Information

Angel Tree

SECTION 2. Camper Emotional & Behavioral History

SECTION 3. Medical Information