POWERHOUSE APPLICATION
Applications for minors should be completed by a parent/legal guardian.
Payment Information:
Payment in full preferred.
Registration must include a $10.00 non-refundable (only transferable) deposit.
Do not send cash.
Registration & Checks or Money Orders Only
Checks Payable to:
Tennessee Church of God of Prophecy
C/O POWERHOUSE
P.O. Box 2319, Hendersonville, TN 37077-2319
Rates:
Onsite Pre-Registration postmarked by 10/25..…………….………$50.00
Onsite Late Registration postmarked after 10/25..……………….$60.00
Offsite Registration (Meals only).………………………..…….….………$30.00
Staff - No Fee
Pastors’ Kids - 50% Discount
Camper's Name
*
First Name
Last Name
Parent or Camper's Personal Email
*
example@example.com
Camper's Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Present Age
*
Camper's Gender:
*
Male
Female
Camper's T-Shirt Size:
*
Small
Medium
Large
XL
2XL
3XL
Church Camper Attends:
Example: Gallatin Church of God of Prophecy
Cabin Roommate Preference:
Multiple names if needed.
PARENT or LEGAL GUARDIAN INFORMATION
Father's Full Name
First Name
Last Name
Does father have legal custody?
*
Yes
No
Father's Address (Write "Same" if same as camper):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Work Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Cell Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Full Name
First Name
Last Name
Does Mother have legal custody?
*
Yes
No
Mother's Address (Write "Same" if same as camper):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Work Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Cell Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY CONTACT INFORMATION
Emergency Contact 1 - If parents or legal guardians cannot be reached, please notify:
First Name
Last Name
Emergency Contact 1's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 - If parents or legal guardians cannot be reached, please notify:
First Name
Last Name
Emergency Contact 2's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
AUTHORIZATION TO PICK UP CAMPER
Name(s) of People Authorized to Pick Camper Up:
Names other than parents/legal guardians who are authorized to pick up camper.
Authorized Contact 1:
First Name
Last Name
Authorized Contact Phone Number 1:
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Contact 2:
First Name
Last Name
Authorized Contact Phone Number 2:
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Contact 3:
First Name
Last Name
Authorized Contact Phone Number 3:
Please enter a valid phone number.
Format: (000) 000-0000.
Minor Camper Self Transport
I understand that my minor camper has provided their own transportation to this event and give my permission for my minor camper to sign themselves out of this event. Parent/Guardian/Camper (if over 18):
Signature - You have read & understand the above statement.
Parents/Legal Guardian sign if the camper is under 18 years of age. Please explain this to your camper.
Statement of Certification and Understanding
I certify that all information provided on this application is accurate to the best of my knowledge. I understand that, in signing this application, I am agreeing to abide by all policies and discipline of the Powerhouse retreat sponsored by the Church of God of Prophecy, its administration, staff, and personnel. Any conduct incompatible, inconsistent, or conflicting with the mission of the Powerhouse Retreat as a Christian retreat will constitute reason or cause for dismissal from the retreat and/or the decision to refuse acceptance to future retreats. I also understand that there will be photography/video taken throughout the weekend and these images may be posted to Facebook on the Camp Hickory Hills Facebook page or other social media outlets. If you do not wish for your child to be in videos or photos, please attach a note stating this request, sign, and date it. Parent/Guardian/Camper (if over 18)
Signature - You have read & understand the above statement.
*
Parents/Legal Guardian sign if the camper is under 18 years of age. Please explain this to your camper.
Statement of Certification & Understanding - Date of Signature:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Statement of Certification and Understanding
Baptismal Release:
Water baptism is sometimes offered to campers during Powerhouse. We, the Church of God of Prophecy, teach water baptism as an outward expression of our commitment to follow Christ and His example. This does not make a person a member of the church. Please check an option below:
I release this minor to be baptised:
Yes, this camper has my permission to be baptized.
No, this camper does not have my permission to be baptized.
Water Baptism Release Signature (Must sign if "Yes" was checked):
Parents/Legal Guardian must sign if the camper is under 18 years of age.
Water Baptism - Date of Signature:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Statement of Certification and Understanding
MEDICAL INFORMATION
Medical Conditions, Allergies, Recent Operations, or Special Needs:
Medications (Please list medications taken on a regular basis)
INSURANCE INFORMATION
Insurance Company:
Insurance ID#:
Medical Consent:
In the case of an emergency, I understand that every effort will be made to contact me (parent/guardian). In the event I cannot be reached, I hereby give my permission to the camp director and physician selected by the camp to secure proper treatment for, to hospitalize, and to order injection, anesthesia, and/or surgery for the camper. I understand that if any accident or sickness should occur which is not covered by camp insurance, it is my responsibility and the camp will not be liable for any of the expenses incurred in such cases.
Signature for Medical Consent:
*
Parents/Legal Guardian must sign if the camper is under 18 years of age.
Medical Consent - Date of Signature:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Statement of Certification and Understanding
I understand that I must make a deposit or full payment to secure my application. Clicking the payment button submits the application & takes me to the payment site.
*
I Am Paying a Deposit or In Full
My church Is Paying Tuition (Church must authorize)
Submit
Should be Empty: