2025 Registration Form (Camper and Sponsor)

Day Camp (July 14) Camptivities

Break-out activity; a Camptivity may need to be assigned by camp director for registrations received after July 6
Galaxy Jar - Girls will create galaxys in jars.

Happy Faces - Girls will choose from a selection of designs to get their face painted.

Bookmarks - Girls will create creative bookmarks. (FULL)

Sports Fun - Girls will enjoy time outside playing a varity of games.

Camptivities will be select for all girls registrering after the late deadline.
Day Camp Camptivities CHOICE ONE

Galaxy JarHappy FacesBookmarksSports Fun
Day Camp Camptivities CHOICE TWO

Galaxy JarHappy FacesBookmarksSports Fun

Medical and Emergency Contacts
Camper Birthday*

MonthDayYear
Date
Parent / Guardian*

First NameLast Name
Parent / Guardian Phone Number*
Please enter a valid phone number.
Parent / Guardian Email*
Contact info is used only for Girls Camp
Relative or Emergency contact(s) (names and phone)*
Medical Limitations / Factors affecting participation (if any)
Allergies (Medical and Food)
Please make sure you to list out any and all foods that your child an not have. This allows us to make sure we have meals planned accordingly.
I give permission for my child to receive over-the-counter pain reliever (i.e. acetaminophen) from event first aid personnel if needed with any exceptions listed on this form.*

Yes
All required vaccinations are up to date.*

YesNo
Current Medications (medication & when taken). All Medications Must be in original containers. All medicine including over-the-counter medicine needs to be turned into the the Camp Nurse at registration. Camper can not have any medication with them. All medication has to be administered by the Camp Nurse.
Physician*
Insurance*
I authorize medical treatment as needed for this camper/child. It is understood that this authorization is given in advance of any specific diagnosis or treatment. I hereby waive all claims against and hold harmless the High Plains Retreat Center and its staff/leaders from any liability for any injuries received by this camper while participating in camp programs. The camper listed has permission to participate in all activities including transportation and water activities. I understand that campers who do not cooperate with leaders or abide by camp rules may be asked to leave. Parents will be responsible for transportation and transportation costs if the camper is sent home.
Parent/Guardian Signature*

Clear
Camper/Sponsor Signature*

Clear
Today's Date

MonthDayYear
Date

Challenge Elements Release Form
Participant’s Name*

First NameLast Name
Date of Birth*

MonthDayYear
If minor, Age
For and in consideration of my being allowed to participate in this program, I agree as follows:

ASSUMPTION OF RISKS
High Plains Retreat Center or HPRC, Challenge Elements involve a variety of activities including warm ups, discussion/debriefing, games, group initiatives (physically and cognitive), zip line and 2-person giant swing elements and other potentially rigorous physical/emotional activities. The inherent risks and other risks of this program may include falls, heat stroke, hypothermia, anxiety and other fear responses, elevated heart rates, collisions with objects or other people, unsafe acts by other participants, acts of nature related to being in outdoor venues, and other risks that may or may not be noted by participants and staff. Safety is an important priority in the facilitation and management of all levels of programming, however, even with the adherence to recognized risk management practices in adventure programming, accidents do occur. Participation in all of these activities and elements may result in injury, fatigue, psychological stress, or even death, not totally unlike other physically and emotionally demanding activities of various natures. The level of participation in our program is entirely voluntary and under individual choice at all times and for ALL aspects of the program or training. As with any program of this nature, there is a risk that must be assumed by each participant in the event that she/he may experience any emotional or physical injury or death.I recognize that there is a significant element of risk in any adventure sport or activity associated with the outdoors. Knowing the risks, dangers, and rigors involved in the activities, I represent that I/my child exhibit(s) good health required for participating in the activities.

VOLUNTARY RELEASE OF LIABILITY AND INDEMNITY
By signing this release form, I agree to release and hold harmless, High Plains Retreat Center or HPRC. its agents, assistants, employees, and, officers, and directors (the “release parties”) for any damage or injuries, physical or mental, including those caused in whole or in part by the negligence of any released party, which I might incur as a result of my voluntary decision to participate in the Challenge Elements.

Participant Agreement including Assumption of Risks and Voluntary Release & Indemnity I further agree to indemnify the release parties and each of them from any claim brought by a third party, including a co-participant, for any injury or loss suffered by that person caused in whole or part by my conduct. This release is binding on my heirs and estate. I acknowledge that I have been given the opportunity to ask questions regarding any aspect of this release form, and by signing in the space provided, do acknowledge that I have read completely and fully understand all aspects of this release from and agree to its terms in their entirety. I have been informed of the full nature of this program and its inherent risks and fully understand the nature of the program.
I certify approval and represent that I/my child can participate in the physical requirements of challenge and recreational activities which involve potential injury and assume such risks. Knowing the risks, dangers, and rigors involved in the activities, I represent that I/my child exhibit(s) good health required for participating in the activities. I understand that participation in this program is by choice and that I/my child may exercise the option to NOT participate in any aspect of these programs. I grant permission for Retreat Center personnel or event leadership to authorize any emergency medical care, operations and/or anesthesia which might become necessary.*

Yes
Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Participant Signature or Signature of Parent/Guardian if under 18*

Clear
Participant Name or Name of Parent/Guardian if under 18

Clear
Today's Date

MonthDayYear

Payment*

Camper - Resident Camp - $260 Full Balance + $10 Late FeeCamper - Resident Camp with One Extra Activity - $280 Full Balance + $10 Late FeeCamper - Resident Camp with Two Extra Activity - $300 Full Balance + $10 Late FeeCamper - Day Camp - $60 Full Balance + $10 Late FeePay Deposit Only - $60 Deposit + $10 Late FeeBeing Paid OfflineSponsor - BOTH - $150 + $10 Late FeeSponsor - Resident Camp Sponsor: $140 + $10 Late FeeSponsor - Day Camp Sponsor: $60 + $10 Late Fee
Amount Due
Amount Due

prevnext( X )
USDGirls Mission Camp 2025
If you are paying online you will be directed to another screen to pay after you click the submit button.
Should be Empty:

Camper Information

Day Camp (July 14) Camptivities

Resident Camp Camptivities

Medical and Emergency Contacts

Challenge Elements Release Form