PA COG YOUTH CAMP - JUNIOR CAMP STUDENT REGISTRATION

Junior Camp is open to students ages 7 - 12

I certify that I am the parent/legal guardian for the student below. *

Yes

STUDENT INFORMATION

Camper's Last Name *

Camper's First Name *

Sex

Male Female

Birth Date

Month Day Year

Camper's Age as of June 30, 2018 *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent's/Guardian Name *

Last Name First Name

Parent/Legal Guardian Driver's License Number *

List State and Number

Primary Contact's Cell Number *

Secondary Contact's Cell Number

Primary Contact's E-mail *

Camper *

Returning New

Church attending camp with: *

List City & Church Name

PASTORAL ENDORSEMENT *

First Name Last Name

Pastor's Ministerial File Number *

Pastor's Phone Number *

- Area Code Phone Number

Pastor's Email

example@example.com

Church of God

Yes No

CAMP SELECTION

Before completing this form, be sure your child's age matches the requirements for the camp as shown above. If you have questions concerning age, please contact pacoggirlsclub@comcast.net

July 4th - 7th *

Camp fees listed include 3% credit card processing fee.

T-Shirt Size (if applicable)

Small Medium Large Adult Sm. Adult Med. Adult Lg

I hereby acknowledge that it is my desire for my child to be a participant in the 2018 Pennsylvania Church of God Youth Camp, including all activities associated with this event; as well as transportation to and from this event and all related activities.

I AM (MY CHILD IS) VOLUNTARILY PARTICIPATING IN THIS EVENT, INCLUDING TRANSPORTATION TO AND FROM THIS EVENT AND ITS RELATED ACTIVITIES, WITH KNOWLEDGE OF THE DANGERS INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY AS A RESULT OF SUCH PARTICIPATION AND TRANSPORTATION.

As lawful consideration for permitting me (my child) to participate in the 2018 Pennsylvania Church of God Youth Camps including transportation to and from this event and all it’s related activities, I hereby release and discharge the Church of God Offices and Church of God Youth Camp, its officers, employees, agents and members of the Board of Trustees from all actions, claims or demands I and my heirs, distributes, guardians, legal representatives or assigns now have or may hereafter have for any injury or damages resulting from the negligence or other acts, howsoever caused, by such church, officers, employees, agents and Board of Trustees, before or during my (child’s) participation in this sponsored activity on and/or away from these premises, including transportation to and from the group activity area and other transportation provided for related activities.

I approve of my child’s participation as a part of the 2018 Pennsylvania Church of God Youth Camp program, including any mission project or activity conducted outside of the Bongiorno Conference Center, Carlisle, PA.

My child will participate as a camper in the Church of God Youth Camp Program which runs from July 4 - 7, 2018.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT IT IS A RELEASE OF LIABILITY AND AN ASSUMPTION OF RISKS AND I SIGN IT OF MY OWN FREE WILL. This Consent and Release from Liability shall remain effective until revoked in writing and delivered to any officer, employee or agent of the Pennsylvania Church of God State Office. *

Yes

List All Medical Conditions:

Current Medications Being Taken:

List all restricted activities:

Allergies, Type of Reaction and Treatment Given:

Note for Nurse:

I hereby give permission to the camp nurse to administer any of the following over the counter medications to my child as needed, in the dosage appropriate based on my child's age and size:

Acetaminophen Aspirin Ibuprofen Anti-Acid Pepto Bismol Imodium AD Cough Drops

If your son/daughter is covered for sickness/injuries by your family insurance, please complete the following form.

Is Camp Staff authorized to approve medical treatment?

Yes No

Is camper covered by personal/family medical insurance?

Yes No

Name of Insurer

Policy or Group Number

Name *

First Name Last Name

Relation to Camper *

Phone Number *

- Area Code Phone Number

In case of medical emergency, I hereby give my permission for the staff member in charge to hospitalize and/or secure the services or a licensed physician, surgeon or anesthetist in providing necessary care for my child as named on this release form. I certify that my child is in good physical condition and is able to participate in the entire camping program except for activities listed as “restricted”.

*

Yes No

MODEL RELEASE: I also consent to the use of any video footage, photos, or any other visual or audio reproduction in which my child may appear by Pennsylvania Church of God Youth & Discipleship. I understand that these materials are being used only for the promotion of Pennsylvania Church of God Youth & Discipleship, which may include recruitment and fund-raising efforts. I release the Pennsylvania Church of God from any liability connected with the use of my child’s picture or voice recording as part of any promotional, recruitment or fund-raising program. *

Yes No

Cellphone Policy: Students are discouraged from bringing cellphones with them to camp. Cellphones and any other electronic devices are expensive and can get lost or stolen, and the physical nature of camp is not kind to such items. However, if you choose to send a cellphone with your student please understand that they will be permitted to use them only during the specified times and cellphones will otherwise need to remain in the cabin.

I (Parent/Guardian) have read the statement regarding the Camp Cellphone Policy *

Yes

I (Camper) have read the statement regarding the Camp Cellphone Policy *

Yes

Camper Pledge: I hereby pledge my word of honor that I will abide by the rules and regulations of the camp during my stay, with the understanding that failing to do so will result in my being sent home from camp.

I (Student) have read and agree the above camper pledge *

Yes

PAYMENT INFORMATION

Enter Total Cost of Camp

USD Includes registration fee and t-shirt fee (if applicable)

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Payment: You will receive a receipt via Square when your credit card transaction is complete. Transaction will appear as PA Youth & Discipleship on your credit card statement.

Confirmation: Once your application has been processed you will receive a post card via email confirming your students registration and all pertinant information concerning camp. Due to the volume of applications received processing times vary.

Please Note: We want to ensure a safe enviroment for our students. Because of this, our camp will be a "closed campus". We will not be accepting visitors. Thank you for understanding. In case of emergency call: 717.234.7381 (camp office)

Thank you for registering for PA Junior Camp 2018!

You will receive a confirmation email with important information soon.

2018 CHURCH OF GOD YOUTH CAMP

Parental/Guardian Consent and Release of Liability

Medical Information

Emergency Contact Information