2025 CT District UPCI Senior Camp Application

2025 CT Senior Youth Camp
We are excited to welcome you and your Senior Camper to the 2025 Senior Youth Camp!

Our program is specifically designed for ages 12-18, and will provide an incredible week of fun, sports, games, meeting new friends and seeing old ones. Most importantly, the week will be filled with learning, prayer, worship, preaching, amazing times in the presence of God.

This application process includes the necessary forms that must be completed. Medical Forms MUST be downloaded, printed, completed by the specified medical practioners, and then Uploaded. No camper will be allowed to register without complete, signed forms present. We understand that most school districts require students to have completed physicals within 2-3 year periods. With that in mind, the CT District UPCI Youth Camp Health Exam/Record for Campers and Staff may be substituted with a school board approved form that has been completed within the last 36 months.

Any questions regarding the application must be addressed prior to camp registration. Failure to do so may result in an incomplete application. Questions can be directed to Nathan Hardt at ctyouthupci@gmail.com or 860-497-5075.

To make the Sr Youth Camp Experience more complete, safe and enjoyable, consider these details:

Age Requirements
- Minimum Age – Camper must be 12 by August 3, 2025
- Maximum Age – Campers who are over 18 by August 3, 2025 must receive special approval from both their pastor and the Youth President.
If your Camper is younger than 12 year on August 3, 2025, please do not complete this application. You can find a Junior Children's Camps Application here.

Important Information
- Pre-registraton ends July 21, 2025
  - The total cost of camp is $250.00 per camper.
  - A Deposit of $25 is required to secure the pre-registration.
- Registrations received after July 21, 2025 will be charged $275.
  - A deposit of $25 is required to secure the registration.
- Full payment may be made with this application or the balance is due upon registration at the campground.
- This application will not be considered complete without all of the following:
  - Deposit
  - Completed & signed Application - (App Pages 1-4)
  - Completed & signed Medical Forms – (CT District UPCI Youth Camp Health Exam/Record, Authorization for the Administration of Medication by Youth Camp Personnel, Individual Plan of Care for a Child with Special Health Care Needs or Disabilities)
  - A $25 late fee will be charged without regard if completed after July 21, 2025.
- If payment is made by check at camp registration, please make all checks payable to “Connecticut District Youth Ministries.
Entire Application Packet Must Be Completed – please use the following checklist

 App Page 1 – Connecticut District UPCI Senior Youth Camp Application

 App Page 2 – Lice Policy, 2025 Senior Youth Camp Program Rules

 App Page 3 – Health History, Allergies, Diet and Activity Restrictions, Individual Plan of Care, Medications, Over The Counter Medications, Youth Camp Health Exam/Record for Campers and Staff
- Authorization for the Administration of Medication by Youth Camp Personnel are only needed *IF* your child is bringing prescription(s) and over the counter medicines to camp – each medicine requires a separate form filled out by parent/guardian and physician. This is required by Connecticut statute. You may make as many copies as needed to cover each medicine the camper is bringing to camp.
- All perscription medications require a perscription label on the original container or a box dated within one year of camp.
- All medications must not be expired in order to be administered by staff personnel at camp.
- All medical forms (including medication forms) are required to be dated and signed by the physician within one year of camp.
- Individual Plan of Care – If camper has food or other allergies requiring an Epi-Pen, the Epi-Pen must be brought to camp. Camp does not provide Epi-Pens. Epi-Pens require the completion of an Individual Plan of Care form.
- An individual plan of care may be necessary for intermittent actions; such as for behavioral responses for an autistic child.
- Individual plans of care would likely be required for campers with asthma specifying preventative measures to avoid asthma triggers and steps to take when an attack occurs.
- If a child has an allergy to insects or food and has an order for an EpiPen, an individual care plan would be required as special care would be necessary during camp. Such special care may include steps to take to avoid an allergic reaction and actions to take in the event of a medical emergency.
 App Page 4 – Informed Consent, Release Agreement, And Authorization

 App Page 5 – CT District UPCI Youth Camp Immunization Exemption Request
- To be completed only if parent/guardian opts out of immunizations for the camper.
Camper Supplies
The Camper will need
- Bible and note book
- Towels, washcloths, soap, shampoo, toothbrush, toothpaste, brush/comb, etc.
- Clothes for 5 church services (most campers choose to dress up for evening services but it is not required. Nice casual is fine too).
- Active clothes for 5 day sessions with activities. There will be water related events during 1-2 days of recreation, so please pack appropriate clothing for this as well.
- Bedding - twin size top and bottom sheet with a light blanket or sleeping bag and pillow.
- Cash for Canteen (drinks and candy are available during the day. After evening service, grilled food is also available).

App Page 1

Connecticut District UPCI Youth Camp

Senior Youth Camp Application

August 3-8, 2025
Camper Information:
Camper's Name*

First NameLast Name
Camper's Age*
Camper's Birthday*

MonthDayYear
Date
Camper's Sex*
Camper's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information:
Parent/Guardian Name #1*

First NameLast Name
Relationship*
Email*
example@example.com
Preferred Number*
Please enter a valid phone number.
Alternate Number
Please enter a valid phone number.
Parent/Guardian #2

First NameLast Name
Relationship
Email
example@example.com
Preferred Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Emergency Information:
Emergency Contact #1 (if not Parent or Guardian listed above)

First NameLast Name
Relationship
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact #2 (if not Parent or Guardian listed above)

First NameLast Name
Relationship
Email
example@example.com
Phone Number
Please enter a valid phone number.
Church Information
Church you attend:*
Pastor's Name:*
Pastor's Email*
example@example.com
Camper, have you been baptized in Jesus Name?*
Camper, have you received the Holy Ghost?*
Health Care Information
Primary Care Provider Name*

First NameLast Name
Primary Care Provider Phone Number*
Please enter a valid phone number.
Primary Care Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Company
Phone Number
Please enter a valid phone number.
Policy Holder
Member #
Policy #
Insurance Card Front and Back Upload (Please use the following format for naming the file; "lastname firstname Ins"*

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App Page 2
Please read the following Policies & Rules:

Lice Policy

All campers will be checked by qualified camp staff for Head Lice prior to registration check-in at the campground.
- If nits or lice are present, campers will be turned away with full refund issued.
- If campers are found to have lice after having been admitted, they will be sent home to be treated by their parents.
- Campers can only be readmitted if there are not nits or lice present and their clothes and bedding has been commercially laundered. Returning campers will be checked prior to readmittance.
2025 Senior Youth Camp Program Rules
1. No registered camper will be permitted to leave the campgrounds at any time, with or without the parents after registration, unless the Camp Program Director has granted previous permission.
2. Only those campers who have registered will be permitted to attend any Camp Program classes.
3. No camper should ever leave their dorm or room at night for any reason without their counselor’s knowledge.
4. Do not exchange dorm space without the approval from the Camp Staff.
5. Do not leave electrical appliances on when not in your room.
6. Air conditioners are not allowed. Fans are allowed.
7. No communication devices are allowed, including cell phones, smart watches, iPads, tablets, etc. If you bring them, they will be confiscated.
8. No electrical/portable musical sources or gaming devices are allowed, such as MP3 players, iPads/Pods, Nintendo Switch, etc. If you bring them, they will be confiscated.
9. Respect other people’s property.
10. Do not leave valuables in the dorm.
11. Girls’ dorms are off limits to boys and boys’ dorms are off limits to girls.
12. “Lights out” will be ½ hour after curfew.
13. Any food received from the canteen will be paid for above and beyond the registration fee.
14. All campers are expected to wear proper clothing as prescribed by the CT District UPCI.
  1. Boys – Shirts are to be worn at all times except in the dorm. No Shorts outside of dorm.
  2. Girls – No pants. Dresses/Skirts should come to the knee. No make-up.
  3. ALL – No earrings, necklaces, shorts, tank tops, or cut-off shirts allowed. No sleeveless shirts or dresses. No tight fitting or revealing clothing. If you do not comply, you will be asked to change, and if you do not change, you may be dismissed from the rest of camp.
15. There will be no physical contact between girls and boys, including holding hands.
16. Attendance is required at all classes, activities and services. Children not registered in Camp will only be permitted in the main service if they are accompanied by an adult who will be responsible for them throughout the service.
17. Any damage to Camp property is the responsibility of the individual.
18. Each camper will be expected to respect Junior and Senior Camp Staff as well as Evangelical Christian Center Staff at all times.
19. The right is reserved to formulate any rule or regulation deemed necessary.
20. Campers may not lock the dorm doors; or in any way modify their room. If they notice damage to the room upon arrival, they should notify their counselor.
Any camper who violates the above Camp Program Rules may have their stay on the campgrounds terminated. The CT District UPCI Camp Director will determine such action.
By placing a signature below, the camper and parent agree that the camper will abide by these rules as a condition of attendance at Senior Youth Camp.

The Senior Youth Camp Program Rules have been read with my son/daughter/ward and we agree to observe them as long as Camp is in session. We/I the undersigned parent(s) guardians(s), hereby grant(s) the Connecticut District UPCI Youth Camp and the Evangelical Christian Center the authority to take temporary care of the applicant. This grant of temporary authority shall begin on August 3, 2025, upon registration, and shall remain effective through August 8, 2025, or upon departure from the Campground.
Signature of Senior Camper*

Clear
Signature of Parent or Guardian*

Clear

App Page 3
Health History
General Health History
- For all YES answers, please provide additional details that would be helpful to health staff.
- Are you currently being treated or have you ever been treated for any of the following conditions?
Have COPD?*
Details
Have ear/eyes/nose/sinus problems?*
Details
Had lung/respiratory disease?*
Details
Has asthma?*
Details
Has seizures?*
Details
Has head injury/concussion?*
Details
Have diabetes?*
Last HbA1c Percentage
Last HbA1c Date
Does your camper have any allergies staff needs to be aware of?
Allergy
Reaction
Anaphylaxis Risk?
Bringing Epi-Pen?
Allergy
Reaction
Anaphylaxis Risk?
Bringing Epi-Pen?
Allergy
Reaction
Anaphylaxis Risk?
Bringing Epi-Pen?
Any other medical condition not covered above?*
Details
Describe the special health care need or disability, unless already described in the Allergies section. (An Individual Plan of Care form will need to be completed and uploaded.)
Diet & Activity

Diet Restrictions
Any diet restrictions?*
Vegetarian?*
Vegan?*
Kosher?*
Are there any other Diet Restrictions or Activity Restrictions that would be imposed on a child's participation in connection with programs or activities that Camp Staff needs to be aware of?*
Details
Does your camper have any other needs of which staff should be aware? Please include information such as bed wetting, fear of the dark, other phobias, anxieties, issues, etc.*
Description of Need/Issue
Suggestion actions to be taken
Individual Plan of Care

Section 19a-428-3 of the Regulations of Connecticut State Agencies requires a child's health record to include information regarding disabilities or sprcial health care needs such as allergies, special dietary needs, dental problems, hearing or visual impairments, chronic illness, developmental variations or history of contagious disease, and an individual plan of care for the child with special health care needs or disabilities. The plan shall be developed with the child's parent(s) and health care provider and updated as necessary. Such plan of care shall include appropriate care of the camper in the event of a medical or other emergency and shall be signed by the parent(s) and staff responsible for the care of the camper.

Click the link below to download the form.

Individual Plan of Care
Individual Plan of Care Upload (Please use the following format for naming the file; "lastname firstname IPC"

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Medications
Please complete the information below regarding any and all medications your camper will bring to camp.

Connecticut schools, licensed Child Care Centers and Group Care Homes, licensed Family Care Homes, licensed Youth Camps administering medications to children shall comply with all requirements regarding the Administration of Medications described in the State Statutes and Regulations. Parents/guardians requesting medication asministration to their child shall provide the program with appropriate written authorization(s) and the medications before any medications are administered.
Authorization for the Administration of Medication forms expire one year from the date they were signed.*

I Understand The Above and Will Comply.

Rows	Medication	Strength	Dose Form	Dose Qty	Time of Day
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8

Medications must be in the original container and labels with the child's name, name of the medication, directions for medication's administration, and the date of the prescription.*

I Understand The Above and Will Comply.
Authorization for the Administration of Medication by Youth Camp Personnel

I request that medication be administered to my child/student as described above.

I hereby request that the above ordered medication be administered by school, child care and youth camp personnel and I give permission for the exchange of information between the prescriber and the school nurse, child care nurse or camp nurse necessary to ensure the safe administration of this medication.

I understand that each medication will require the completion of the Authorization for the Administration of Medication by School, Child Care, and Youth Camp Personnel form.

All forms must be uploaded prior to the start of camp, and must be provided to complete the camper's registration.

Click here for the Authorization for the Administration of Medication by Youth Camp Personnel Form.
Authorization for the Administration of Medication by Youth Camp Personnel Upload Here (Please use the following format for naming the file; "lastname firstname AAM"

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Over the Counter Medications Authorization

The following non-prescription medications may be stocked in the camp Health Center and are used on an as-needed basis to manage illness and injury. Prior authorization is required for dispensing. Select NO for any medications the camper should not be given.
Acetaminophen (Tylenol) 325mg Tabs?*
Acetaminophen Chewable (Tylenol) 160 mg tabs?*
Aloe?*
Bismuth Subsalicylate (Kao pectate / Pepto-Bismol?*
Calamine Lotion?*
Calcium Carbonate Chewables (Tums)?*
Cough Syrup (Robitussin DM)?*
Dextromethorphan (Delsym) 15mg/5ml?*
Diphenhydramine (Benadryl) 25mg tabs?*
Diphenhydramine Chewable (Benadryl) 12.5mg tabs?*
Hydrocortisone creme 1%?*
Ibuprofen (Advil) 200mg tabs?*
Ibuprofen Chewable (Advil) 100mg tabs?*
Insect Repellent?*
Loratadine 10mg tabs?*
Cough Drops (Generic)?*
Phenylephrine HCL (Suphedrine PE) 10mg tabs?*
Sunscreen?*
Tolnaftate creme 1%?*
Triple Antibiotic Ointment (Neosporin)?*
Any other Over The Counter Medications not listed above will require an Authorization for the Administration of Medication form to be completed.*

I Understand The Above and Will Comply.
CT District UPCI Youth Camp Health Exam/Record for Campers Form

Please download and print a blank CT District UPCI Youth Camp Health Exam/Record for Campers Form. The Health Exam/Record Form must be completed by a healthcare provider and the completed form must be uploaded below. The Health Exam/Record form may be substituted if the camper has a valid school board approved form completed within the last 36 months.

Physical Exams are Valid for 3 Years from Date of Last Exam.
Click here to download the CT District UPCI Youth Camp Health Exam/Record for Campers and Staff
Upload Completed Health Exam/Record Form here. (Please use the following format for naming the file; "lastname firstname Health"*

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App Page 4
INFORMED CONSENT, RELEASE AGREEMENT, & AUTHORIZATION
Camper's Date of Birth*

MonthDayYear
Date
Camper's Name*

First NameLast Name
I understand that participation in CT District UPCI Youth Camp activities involves the risk of personal injury. I understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and standards of conduct.

In case of an emergency involving (me or) my child, I understand that all efforts will be made to contact the individual(s) listed as the emergency contact person by the medical provider and/or the camp staff. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the CT District UPCI Youth Camp director to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for (me or) my child. Medical providers are authorized to disclose protected health information to the camp staff in charge, camp medical staff, camp management, and/or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PH/CHI) under the Standards for Privacy of Individually Identifiable Health information, 45 C.F.R. ss 160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for the purposes of medical examination of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

(If applicable) I have carefully considered the risk involved and hereby give my informed consent for my child to participate in all activities offered in the program. I further authorize the sharing of the information on this form with any CT District UPCI Youth Camp/CT District UPCI volunteers or professionals who need to know of medical conditions that may require special consideration in conducting camp activities.

With appreciation of the dangers and risks associated with programs and activities, (on my own behalf and/or) on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the CT District UPCI Youth Camp, the CT District UPCI, the activity coordinators, any and all employees, volunteers, related parties, or other organizations associated with any program or activity.

I also hereby assign and grant to the CT District UPCI Youth Camp, the CT District UPCI, as well as their authorized representatives, the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of (me or) my child at all CT District UPCI Youth Camp activities, and I hereby release the CT District UPCI Youth Camp, the CT District UPCI, the activity coordinators, any and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the CT District UPCI Youth Camp or the CT District UPCI, and I specifically waive any right to any compensation I may have for any of the forgoing.

Note: Due to the nature of programs and activities, the CT District UPCI Youth Camp and the CT District UPCI staff cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical providers. However, so that the staff can be as familiar as possible with any limitations, any restrictions imposed on a child participant in connection with programs or activities must be listed on App Page 3 where appropriate.

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. The participant has permission to engage in all activities described, except as specifically noted by me or the health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.
Participants Signature (if over the age of 18)

Clear
Date Signed by Participant

MonthDayYear
Date
Parent/Guardian Signature (if participant is under the age of 18)*

Clear
Date Signed by Parent/Guardian*

MonthDayYear
Date

App Page 5

CT DISTRICT UPCI YOUTH CAMP

IMMUNIZATION EXEMPTION REQUEST
On religious, philosophical, or medical grounds, I request exemption for me and/or my child from all vaccinations and/or immunizations recommended by the American Academy of Pediatrics and National Advisory Committee on Immunizations Practices for attendance to the CT District UPCI Youth Camp. I understand that a medical evaluation and screening by a licensed health-care practitioner is necessary to reduce the possibility of exposing other camp participants to a communicable disease.

In consideration of these exemptions, I understand that I accept complete responsibility for the health of me and/or my child , and I hereby release and agree to hold harmless the CT District UPCI Youth Camp, CT District UPCI and any of it’s officers, agents, staff and representatives from any liability that might arise during any or all of CT District UPCI Youth Camp activities by virtue of this exemption.

It is further understood that, should an emergency arise, First Name Last Name Area Code Phone Number will be notified immediately. In the event that this contact cannot be immediately located, the CT District UPCI Youth Camp or the CT District UPCI authorities may take such temporary measures as deemed necessary.
Camper's Name

First NameLast Name
Camper's Signature

Clear
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Date of Signatures

MonthDayYear
Date
Parent Information
Parent Name

First NameLast Name
Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Payment
Clicking the links will transfer you to Square.com for payment options. Note:
- The cost of camp is $250 per attendee if registration is completed by the pre-registration deadline of July 21, 2025.
- The late registration fee is $275.
- A $25 Deposit is required with this submission (you will still owe the remaining $225).
You can pay your required $25 Registration Deposit here:

Registration Deposit CT Senior Youth Camp Registration

You can also pay full registration cost ($250) now to save time:

Full Early CT Senior Youth Camp Registration
I have completed the payment link. I understand without payment this registration will not be considered complete.*

I Understand The Above and Will Comply.
Should be Empty:

2025 CT Senior Youth Camp

Camper Supplies

Camper Information:

Parent/Guardian Information:

Emergency Information:

Church Information

Health Care Information

2025 Senior Youth Camp Program Rules

Health History

Does your camper have any allergies staff needs to be aware of?

Diet & Activity

Medications

Over the Counter Medications Authorization

CT District UPCI Youth Camp Health Exam/Record for Campers Form

INFORMED CONSENT, RELEASE AGREEMENT, & AUTHORIZATION

Parent Information

Payment