Presbytery of East Tennessee Summer Camp/Retreat Registration Form

Which event will camper be attending?

For Camp John Speer Summer Camps only: Will the camper be dropped off at Greenville CPC?

If Yes, both ways?

Camper Information

Camper's Name

First Name Last Name

Camper's Cell Phone Number, if applicable

Area Code Phone Number

Birth Date

Month Day Year

Grade just completed

Gender

Male Female

Camper's T-Shirt Size

**Camp Chilhowee Campers only** If you preregister by the following dates, your registration will include a shirt. If you register after the following dates, or on the first day of camp, you may purchase a shirt for $15.00.

Address

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

Home Church

Pastor/Youth Pastor

Camper would like to room with?

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail

How will the camper be getting home

Who is allowed to pick up the camper?

Is there any person NOT allowed to pick up the camper?

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does your child currently have an active IEP or 504 Plan? *

Yes If yes, please contact the Presbytery Youth & Children's Director at 865-705-9885 for further information. No

Insurance Provider

Insurance Group Number

Insurance Policy Number

Please submit a copy of the front and back of Medical Insurance Card.

Browse Files

Camper's Doctor/Medical Provider, address, and phone number

Does camper have an IEP plan or 504 at school? If yes, someone will contact you for details. Our goal is to support each camper.

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the camper prescribed an inhaler? If yes, please explain any instructions.

Do you give permission for staff to give camper over-the-counter medications, if needed? (ibuprofen, acetaminophen, Pepto Bismal, etc.)

If so, any exclusions or additional information needed concerning OTC medications?

Does the camper have an epinephrine pen?

Does the camper have a diabetic pump or shots?

Will camper have medications at camp?

If yes, complete a medical form listing the correct dosage and times to take the medication. (Medication form is needed even if this info is on bottle)

Does the camper have any condition that may require special care, medication, or diet not listed above? If yes, please explain here.

Parental Consent and Release of Liability

To be Completed by Camper' Parents or Legal Guardians

I give my child permission to participate in the event marked above with the Presbytery of East Tennessee, understanding that if my child does not comply with the guidelines set forth by the event leadership, they will be sent home at my expense. When I am not present, I am entrusting my child's care to another responsible adult, whom I expect to make wise decisions on my behalf when I am not available to do so. This permission includes traveling in a vehicle for medical purposes or for activites related to the event, such as, hayrides, transporation to/from hikes, etc. Knowing that the event director and attending chaperones will have my child's best interest and safety in mind, I hereby release the Cumberland Presbyterian Church, the Presbytery of East Tennessee, its member churches, the event director and adult chaperones from any legal liability concerning, but not limited to, any incident that results in injury, illness, or death. I understand that in the case of an emergency, every effort will be made to contact me, but if I am not available or if decisions need to be made quickly for my child's well-being, I defer these decisions to the adult closest to the situation.

Parent/Guardian Signature and Date

Photo/Media Release

To be Completed by Camper's Parents or Legal Guardians

I, the undersigned, do hereby grant permission to the Presbytery of East Tennessee to use the image of my child. Such use includes the display, distribution, publication, transmission or otherwise use of photographs, images, and/or videos taken of my child for use in materials that include, but are not limited to, printed materials, videos, and digital images such as those on a website or social media.

Parent/Guardian Signature and Date

Parent/Guardian Signature if you deny permission for Photo/Media release, please sign and date here.

Clear

Camper's Covenant Agreement

To be Completed by the Camper

I have read and understand the camp guidelines. I am fully aware that a camp experience will require me to make personal sacrifices to which I may not be accustomed Therefore, I hereby: 1. Realize that living as a group will require me to be responsible in my actions and display Christian love and patience toward all members of the group. 2. Realize the importance of all members of the group following a schedule and the guidelines and instructions of the leaders. 3. Agree to participate fully in all activities. 4. Agree to maintain an open mind and heart in the teachings of Christ and for the leadership of the Holy Spirit.

Camper's signature and date

Clear

Spring/Fall Retreat Registration $ 75.00

Church Pays Half of Fee-Spring/Fall Retreat Church Pays Full Registration Fee-Spring/Fall Retreat

Enter coupon

Total $ 0.00

Enter Coupon code church50 if your church pays half of camp fees.

Enter Coupon code church100 if your church pays the full reistration fee.

Presbytery of East Tennessee Camp/Retreat Registration

Medical Information