ABCCR Camping 2024
Camper Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Birthday
*
-
Month
-
Day
Year
Date
Grade in the Fall
*
Church
*
Town
*
Name of Youth Pastor or Leader
*
First Name
Last Name
Email of Youth Pastor or Leader
*
example@example.com
Gender
*
Male
Female
Shirt Size
*
Please Select
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
Adult 3XL
Parent/ Guardian Name
*
First Name
Last Name
Parent/ Guardian Email
*
example@example.com
Parent/ Guardian Phone Number
*
Please enter a valid phone number.
List any allergies, including FOOD allergies or special needs for child
*
List any physical or mental conditions that may affect your child at camp (example: bed wetting, ADHD, nightmares, disabilities). Please contact the camp director before completing the registration if your child has special needs to ensure we can accommodate them.
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Relationship to Participant
*
Discipline, Liability, Sickness, & Medical Release I , the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in the event(s) listed above with the American Baptist Churches of the Central Region. The individual identified on this form understands that all participants are expected to abide by the program rules and be directly responsible to their church leader. The event director assumes responsibility for discipline at the program and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning the participant home. Further, I do release and hereby agree to hold blameless ABCCR and its employees and agents from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participating in any activities associated with ABCCR. I also release the lessor/owner of properties on which the Program is held. I agree to pay for any damages or property loss as determined by ABCCR .Further, I do authorize the minister or sponsor of this activity or any ABCCR staff member, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on this trip. I will not hold ABCCR, Camp Christy, or Camp White Memorial at fault for any sickness or illness my child may contract while at camp. We will isolate sick students and if necessary parents will be contacted in order to remove their student from camp. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment. Further, I do certify that said participant is covered by adequate accident insurance. My consent and signature are given below. I have read and agree to the information given in this entire form.
*
Image Release I (We), the undersigned individual(s), grant American Baptist Churches of the Central Region (ABCCR), located at 5889 SW 29th St, Topeka, Kansas, USA, the perpetual, non-exclusive, royalty-free right and license to: Record my participation and appearance on digital or film photography, video, audio or any other medium. Use my name (or any fictional name), likeness, voice and biographical material and information in connection with these recordings to be used only in or for ABCCR written, electronic and web publications, including social media and apps to be used for the promotional material, multimedia and publication purposes of the American Baptist Churches or the Central Region. Reproduce, distribute, publicly display and/or publicly perform, in print, electronic or any other medium, copies of the recordings, in whole or in part. Grantor represents that he or she possesses all rights necessary to grant this permission for and in connection. I am voluntarily making this grant of rights. I further agree to release and forever discharge ABCCR, its agents, employees and designated representatives from any and all claims in law or equity that I, my heirs or personal representatives have or shall have arising out of recordings. I also consent to the use of my child's image by Camp Christy and Camp White Memorial. I am the parent or guardian of the minor named above and have the legal authority to execute the above release. I approve and waive any rights in this release.
*
I give permission for my child/ self to be recorded in any form of media by ABCCR
*
Yes
No
How will you be paying?
*
Online via Credit/ Debit Card
Sending a check
Church pay
Select your White Memorial Camp
Please Select
High School Camp- July 15-19 ($385)
Middle School Camp- July 15-19 ($385)
Junior Camp- July 21-25 ($385)
Select your Camp Christy Camp
Please Select
High School Camp- June 3-27 ($275)
Middle School Camp- June 10-14 ($275)
Junior Camp- June 17-21 ($275)
Primary Camp- June 24-26 ($130)
Day Camp- June 27-28 ($90)
Total
My Products
prev
next
( X )
White Memorial High School Camp
White Memorial, July 15-18
$
385.00
White Memorial Middle School Camp
White Memorial, July 15-18
$
385.00
White Memorial Junior Camp
White Memorial, July 21-25 (Sunday afternoon-Thursday)
$
385.00
Camp Christy High School Camp
Camp Christy, June 3-7
$
275.00
Camp Christy Middle School Camp
Camp Christy, June 10-14
$
275.00
Camp Christy Junior Camp
Camp Christy, June 17-21
$
275.00
Camp Christy Primary Camp
Camp Christy, June 24-26
$
130.00
Camp Christy Day Camp
Camp Christy, June 27-28
$
90.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Expiration Year
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Continue
Continue
Should be Empty: