Clone of 2025 Summer Camp Detailed Registration Form

Youth Camp Registration
TOTAL COST: $30 weekly programming fee; If staying for single nights overnight - donation Please make checks out to Lamar Lighthouse Camp Mail to: Bill Hargenrader PO Box 16, Madisonburg, Pa.16852 Registration and balance of registration due on arrival at camp on Sunday,July 13, 2026 (Your child will not be able to stay if there isn’t a completed registration form upon their arrival.). For information call: Charlee (814) 657-6725.
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Grade (6th- Graduating Senior)
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Home Church
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Medical Insurance (If parents are not participating in camp week)
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Please send only the required dosage of medication neededfor the week/day at camp. The dosage instructions and camper’s name should be clearly printed ortyped and include with the medication. All medication must be turned in to the Youth Directors atregistration.
In the event my child(ren) gets sick during Family Camp, I give permission for Tylenol, Pepto-Bismol, and/or Imodium to be administered.
Date of last Tetanus Shot:
Pictures
I give permission for my child(ren) to go off the campground for pool parties, and trip to Bald Eagle State Park or Krislund camp which will also include swimming and possibly Penns Caves.
Informed Consent and Acknowledgement

Risk/Liability – Hold Harmless Release
I’m fully aware that camping activities involve risk and are sometimes stressful and physically
demanding. I realize that I must act as a responsible member of the group and will not jeopardize the
safety of myself or other members of the group. I understand that the Lamar Lighthouse Camp Staff
will use all safety precautions to insure my wellbeing. Yet I am aware that even with the best safety
standards, incidents may happen, which are beyond the control of the Camp Staff. Knowing these
things, I assume any risk involved, release, and hold harmless the Lamar Lighthouse Camp and its
Staff from any liability due to an accident.
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Lamar Lighthouse Camp and its affiliates including Directors, Counselors to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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.
Date

MonthDayYear
Date
Signature
Should be Empty:

Youth Camp Registration