ENCCOG Youth Camp Online Medical Consent/Liability Release Form
Your Registration will not be complete until this form is completely filled out for each student. It is vital that you read and fill out all information carefully. *This is not a camp registration form. You will need to register your child for camp prior to filling out this form.*
Student Information
Select Camp for Student
*
Kids Camp (June 9-12)
Middle School Camp (June 16-20)
High School Camp (June 23-27)
Gender
*
Male
Female
Camper Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
In Case of Emergency
Emergency Contact
*
First Name
Last Name
Relationship to Camper
*
Emergency Contact #
*
-
Area Code
Phone Number
Emergency Contact Email
*
example@example.com
Alternate Contact #
-
Area Code
Phone Number
General Medical History
Camper Height:
*
Camper Weight:
*
Is the Camper up-to-date all immunizations?
*
Yes
No
Attach immunization record or waiver
Browse Files
Cancel
of
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?
-
Month
-
Day
Year
Date
Does your child have any Allergies? Check all that apply
*
Food
Medication
Environmental
No Known Allergies
Please list and explain any allergies (If not applicable, write N/A)
*
Significant Medical History with Dates (surgery, injuries, serious illness) If not applicable, write N/A:
*
List any Medical Problems (asthma, seizures, headaches, etc.) If not applicable, write N/A:
*
Is any medication required?
*
Yes
No
List any medication taken regularly and dosages (If not applicable, write N/A):
*
My Child is allowed to have (Select All That Apply)
*
Tylenol
Ibuprofen
TUMS
Medical Insurance Details
Write N/A if you do not have insurance.
Name of Insurance Company:
*
Group/Policy Number:
*
Pre-Authorization Required?
*
YES
NO
N/A
If YES, what limits?
Attach copy of Insurance Card (Front & Back)
Browse Files
Cancel
of
Parent/Legal Guardian Signature
*
I understand that all medications brought to camp must be prescribed by a professional doctor and provided in the original containers, otherwise they will not be accepted or administered. I also understand that the Camp Insurance Policy provides secondary coverage, and I must provide primary coverage for my child. I accept all financial responsibilities for medical costs.
Parent/Legal Guardian Signature
*
I hereby give my child permission to participate in any and all aspects of Church of God Youth Camp, including physical, spiritual and social, at the Eastern North Carolina Church of God Conference Center, Kenly, NC. I understand that this is a Church of God camp and doctrines and practices of the Church of God, Cleveland, TN will be taught and practiced. I understand that spiritual ordinances may be administered and practiced. Activities include, but are not limited to, low impact sports, high impact sports, paintball, swimming, etc. If camp activities are off site, I give permission for my child to travel with camp volunteers, employees, and/or agents of the camp. I hereby waive, release, and discharge any and all claims, demands, and causes of action against volunteers, employees, Church of God State officials, the Church of God in Eastern North Carolina, and Church of God International Offices, Cleveland, TN, arising from any damages, property loss, or injuries that I or my child may sustain. If my child causes damage to property through willful destruction and/or by accidental means, I hereby accept financial responsibility to repair and/or replace property at the discretion of Church of God officials. Further, I understand that my child may be denied involvement from any activity for safety precautions or as penalization for disobedience of camp rules at the discretion of officials or volunteers. I further understand that my child may be photographed and/ or videoed for promotional or remembrance purposes. These images will remain the property of the Church of God for use as the Church of God sees fit. I accept full financial responsibility for and hereby consent to allow employees and/or volunteers to obtain emergency medical treatment as they deem necessary for my child. Further, it is understood that my medical insurance, health insurance, or accident insurance (if applicable) will be used as the primary policy and that the Church of God policy will be used as the secondary policy. I understand that campers are allowed to bring cell phones to camp. The camper assumes ALL liability for their cell phone while at camp. There will be certain times during the day and certain areas of campus where cell phone use will not be permitted. Any camper taking a compromising picture of another camper or staff member and makes it public in any way may be subject to dismissal from camp. If the law is broken, the appropriate authorities will be notified. Headphones and/or earbuds are not allowed at camp. In the event a camper disregards this policy, camp staff may confiscate the phone until the end of camp. I understand that if my child breaks the camp rules, or is disobedient to leaders, and is dismissed from camp, I am responsible to immediately retrieve my child from the property.
Save
Submit Form
Should be Empty: