E4N Youth Camp Application 2020

E4N Youth Camp 2021 Application

Fill out the form carefully for registration
Very important Camp information
Camp Tuition:

Camp Tuition: $150.00

Preregistration: $30.00 due by May 10th, 2021. This is non-refundable. The remainder $120.00 is due by May 31, 2021

Check-In:

Check-in will begin at 1 pm on Monday, June 22, 2021, and will continue until 3 pm. All campers must report to the Office upon arrival to receive their room assignments.

Check—Out:

The camp is officially closed at 11 am on Friday, June 26, 2021 Parents should make arrangements to pick up their camper no later than 11 am. All counselor staff will be dismissed at 1 pm. *NOTE: All campers must come to the Office to check-out before leaving the campgrounds. The person responsible for picking up a camper must sign them out. Your cooperation is greatly appreciated in this matter.

WHAT IS E4N YOUTH CAMP?

E4N Youth Camp is a ministry of the Ephesians 4 Network. The camp is operated as a summer youth ministry to provide opportunities for fun, fellowship, and spiritual growth in a Christian environment.
WHAT TO BRING?
1. Bible, notebook, pen

2. Sleeping bag/sheets/ blanket (twin size)

3. Pillow

4. Toiletry items: Soap, deodorant, toothpaste, toothbrush, shampoos, hairbrush, etc.

5. Towels and washcloths

6. Casual/Play/Dress clothes

7. Dirty clothes bag

8. Swim clothes—girls one piece swim suit (No French cuts)

9. Sweater/jacket

10. Shoes (open toe shoes are permitted but you must wear closed toe shoes during sport activities.

11. Money for canteen

12. You may also bring a fan.
How do I contact a camper?
No phone calls are allowed to campers unless it is an emergency. In case of an emergency the camp office number is:

(V) (740) 418-1318

or

(231) 937-6200
Camp Rules
The following rules are necessary for a safe, enjoyable and effective camp. They will be enforced. Failure to comply with these rules could result in dismissal from camp.

1. Everyone is required to follow the camp schedule. This includes all classes, services, recreation and other activities.

2. No one is permitted to leave camp without the permission of the Camp Director.

3. The use of tobacco, drugs, or alcohol is prohibited.

4. Each camper is responsible for taking care of any camp equipment and facilities. Any breakage or destruction of camp property caused intentionally or by carelessness or rough play must be reported and paid for by the camper(s) involved.

5. Only emergency telephone calls will be permitted and these must go through the Camp Director.

6. MP3 Players, cell phones, tablets, iPads, laptops, and all other electronic devices are prohibited and should be left at home.

7. Any conduct or activity out of harmony with the Camp Program will be dealt with accordingly. No PDA (Public Display of Affection)

8. We prefer that no camper drive themselves to camp but if this is the case, they will not be permitted to leave the campgrounds under any circumstance. They will be asked to turn in their keys to the camp director upon arrival at camp and will receive their keys back on check out that Friday.

9. All counselors, and campers who are over 18, must complete the background check form.

10. No medication (Tylenol, aspirin etc.) will be administered to camper unless written authorization from parent/guardian is made to the camp director.
E-Signature Disclaimer
This application is legally binding .By signing the e-signatures below you are agreeing to all terms and conditions listed in this application and here by consent to the information provided. All applications along with their signatures are kept on file for the safety of Ephesians 4 Network, the parents/guardians of the children, and the children. Any and all signatures are documented: chicken scratches, doodles, etc and are considered to be a legal signature by the signer. Please print and sign name below if you are the Parent Guardian. By checking the box below you here by agree to the terms and conditions listed.
I Agree With The Above Terms and Conditions
Parent/Guardian Signature*

Clear
Print Name (Parent/Guardian-Counselors)*
Date*

MonthDayYear
Phone Number*
Email*
example@example.com
Within 24-48 Hours of submitting this application, one of our office staff will contact the parent or guardian responsible for filling out this application. This is to confirm that the legal parent or guardian of this said child filled out this application.

E4N YOUTH CAMP 2021 APPLICATION
This application is for: (please select one)*

CamperCounselor
*Counselors must be 18 years or older.
Complete the following Information about the camper or counselor:
Camper/Counselor Information*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Gender*
Age*
Weight*
Height*
SSN #*
Email*
Medical Conditions/Disabilities*
Allergies*
Home Church/Pastor*
Other*
Full Name

First NameLast Name

Complete the following information about parent or guardian:
Parent or Guardian*

ParentGuardian
First Name*
Last Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Number*

Area CodePhone Number
E-mail*
Work Number*

Area CodePhone Number
Medical Treatment Consent Form and Hospitalzation Insurance Coverage Information
In my absence, I hereby authorize the Director of E4N Youth Camp or his appointee, to obtain medical treatment which may be deemed necessary for my child, I also hereby authorize any physician called upon by the Director of E4N Youth Camp to render medical treatment that, in his judgment, may be deemed necessary for the well being of my child.
Signature*

Clear
*Signature must be signed by Parent/Guardian Only. By signing this you are releasing the child (please fill child's name and your name below) and all responsibilty to the E4N Camp Director.
Date*

MonthDayYear
Parent/Guardian Full Name*
Camper Full Name*
Insurance Company and/or Government Program*
Address*
Subscriber ID/ Contact Number*
Insurance Company Phone Number*

Area CodePhone Number
Preadmission Phone Number*

Area CodePhone Number
Group Name (Employer)*
Group Number*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer's Phone Number*

Area CodePhone Number
Insurance Authorization: I authorize the release of any medical information necessary to process a claim for my dependent named in the E4N Youth Camp Application. I authorize payment of medical benefits to the physician or supplier of service rendered to my dependent.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear

Camp Rules Acknowledgement:
I, have read and understand the Ephesians 4 Network youth camp rules and agree to follow them.
Parent/Guardian Signature*

Clear
Counselor/Camper Signature*

Clear
Date*

MonthDayYear
Activity Permission Form To Be Signed By Parent or Guardian
The undersigned hereby forever releases and discharges E4N Youth Camp and Ephesians 4 Network of any and all liability of any nature which may arise while (please insert your child's name below) is a camper as set forth above. Undersigned further covenants and agrees to never sue or file a claim against the foresaid E4N Youth Camp or Ephesians 4 Network for any injury which may occur to said camper while he/she is involved in any of the activities of E4N Youth Camp, either on or off the premises. WITNESS my hand and seal.
Camper's Name*
Parent/Guardian Siganture*

Clear
Date*

MonthDayYear

Check One Only
Registration*

Pre-registration fee of $30.00 received by May 10, 2021Total Camp Tuition of $150.00 received
Registration includes camp t-shirt.

Please mark shirt size or your child will automatically receive a size large t-shirt.

***If you would like a camp t-shirt you must pre register.***
Shirt size (adult sizes only)*

SmallMediumLargeX-Large2X-Large3X-Large4X-Large
CHECK - OUT - Signature and printed name to be completed at check-out, June 21.
Person Responsible for Picking Camper Up:*
Relationship:*
Signature*

Clear
Please Print Name*
Date*

MonthDayYear

Activities
To be filled out by the camper’s parent or guardian. All participants in the following activities must have a completed and signed form in order to participate in these activities
Camper's Name:*
Date of Birth*
Name of Parent/Guardian:*
Phone Number*

Area CodePhone Number
Is this a good phone number to reach you at anytime*

YesNo
Alt. Phone Number*

Area CodePhone Number
Potentially Hazardous Activities: (please CHECK those items you consent for your minor child to participate in).
Parent/Guardian Signature*

Clear
WAIVER OF CLAIMS

In consideration of the benefits to be derived from participation in the activities of the E4N Youth Camp, any and all claims against Ephesians 4 Network (E4N), the officers, employees, agents, or other representatives of any of them, or any other persons working under their direction or engaged in the conduct of their affairs, arising out of any accident, illness, injury, damage, or other loss or harm to/or incurred or suffered by the participant named above or to his or her property, in connection with or incidental to the activities at IPCC Headquarters, including preliminary training and travel, are hereby expressly waived by the participant and the participant’s family or guardians. This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to this release as provided above. I release and agree to indemnify and hold harmless Ephesians 4 Network from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear

Travel Waiver
TRAVEL WAIVER

I give permission for my child to travel outside the state (please insert what state below) for the purpose of traveling to and from the 2021 E4N Youth Camp, located at the IPCC Headquarters in London,Ohio. This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to this release as provided above. I release and agree to indemnify and hold harmless Ephesians 4 Network from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES to the fullest extent permitted by law
State*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Witness Signature*

Clear
Date*

MonthDayYear

Authorization and Release
NOTE: THIS FORM MUST BE COMPLETED BY ALL COUNSELORS AND ANY CAMPER THAT IS OVER 18 YEARS OLD.
Criminal Background Check
I, the undersigned, having filed an application as a counselor for 2021 youth camp with the Ephesians 4 Network (E4N) conference of the International Pentecostal Holiness Church, consent to have the E4N secure a national criminal background and sex offender check on me as an individual. I hereby release, discharge, and exonerate the Ephesians 4 Network of the International Pentecostal Holiness Church, its agents and representatives and any person furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information or the investigations made by or on behalf of the above-named Conference. The Conference shall not be required to verify any information received during the course of its investigations, and shall not be liable for acting on the basis of any information, which later appears to have been false or incomplete. I have read and signed the foregoing Authorization and Release as my own free act and deed.
Date*

MonthDayYear
Signature*

Clear
Date*

MonthDayYear
Please complete the following and return to us along with your completed application:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Race:*
Gender*
Social Security Number*
NOTE: Compete name, address, DOB, and Social Security Number MUST be included. Without it, your application will not be approved. Please also include your phone number in case there are any questions about your application.
I agree with the above terms and conditions
After submitting your application you will be taken to a separate page where you can then proceed to payment. A registration fee of $30 is required upon submitting the application and the remaining payment is due by May 31, 2021.

Camper Tuition: $150
Counselor Tuition: $100

FAQ: The registration fee is worked into the tuition cost of both campers and counselors. Ex: If you were to submit your registration fee of "$30" for a camper then you would still owe "$120", totaling "$150" for full camper tuition. This is the same for counselors
Camp Tuition*
prevnext( X )
Pre-Registration Fee$30.00

Total Camper Tuition$150.00

Total Counselor Tuition$100.00

Other Payment Arrangement (check, cash, etc)$ Free
The Pre-Registration fee of $30 is required but if you so choose to pay your total camper or total counselor tuition you may do so by selecting the additional options listed above. Please note that if you choose to pay only the $30 registration fee your remaining payment will be due on May 31, 2021.
Total Camper Tuition: $150
Total Counselor Tuition: $100
Would you like to subscribe to our email list?*

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E4N Youth Camp 2021 Application

Very important Camp information

WHAT TO BRING?

How do I contact a camper?

Camp Rules

E-Signature Disclaimer

E4N YOUTH CAMP 2021 APPLICATION

Activities

Travel Waiver

Authorization and Release