CHH Camper Application
Applications for minors should be completed by a parent/legal guardian.
Read Carefully
Please pay full tuition if possible. In the event applicant is unable to attend camp, tuition (with the exception of the $20.00 deposit) is refundable or transferable.Application must be accompanied by a minimum $20.00 non-refundable (only transferable) deposit.
Name
*
First Name
Last Name
Personal Email
*
example@example.com
Camp or Camps Attending:
*
Senior Camp (15-18)
Teen Camp (12-14)
Pre-Teen Camp (10-12)
Junior Camp (8-10)
Big Shot Camp (6-8)
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Present Age
*
Camper's Gender:
*
Male
Female
Camper's T-Shirt Size:
*
Youth Small
Youth Medium
Youth Large
Small
Medium
Large
XL
2XL
3XL
4XL
Church Camper Attends:
Example: Gallatin Church of God of Prophecy
Cabin Roommate Preference:
Multiple names if needed.
Father's Full Name
First Name
Last Name
Does father have legal custody?
*
Yes
No
Father's Address (Write "Same" if same as camper):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Work Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Cell Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Full Name
First Name
Last Name
Does Mother have legal custody?
*
Yes
No
Mother's Address (Write "Same" if same as camper):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Work Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Cell Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Name(s) of People Authorized to Pick Camper Up:
Names other than parents/legal guardians who are authorized to pick up camper.
Authorized Contact 1:
First Name
Last Name
Authorized Contact Phone Number 1:
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Contact 2:
First Name
Last Name
Authorized Contact Phone Number 2:
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Contact 3:
First Name
Last Name
Authorized Contact Phone Number 3:
Please enter a valid phone number.
Format: (000) 000-0000.
Statement of Certification and Understanding
I certify that all the information provided on this application is accurate to the best of my knowledge. I understand that, in signing this application, I am agreeing to abide by all the policies and discipline of the camp (referring to all camps and retreats sponsored by the Church of God of Prophecy), it’s administration, staff and personnel. Any conduct incompatible, inconsistent or conflicting with the mission of Camp Hickory Hills as a Christian camp will constitute reason or cause for dismissal from camp and/or the decision to refuse acceptance to future camps.
Signature - You have read & understand the above statement.
*
Parents/Legal Guardian sign if the camper is under 18 years of age. Please explain this to your camper.
Statement of Certification & Understanding - Date of Signature:
*
-
Month
-
Day
Year
Statement of Certification and Understanding
Swim Release:
For and in consideration of attendance at Camp Hickory Hills by the camper named on this application, we, the undersigned, do hereby release and discharge Camp Hickory Hills, The Church of God of Prophecy (state and international headquarters), the directors and all other staff members of the camp from any and all liability for any injuries suffered by the camper while in attendance at Camp Hickory Hills and while using the swimming area and swimming pool for recreation. In signing this form, the camper and his/her parents (if the child is the age of 18) agree that the camper has full consent and permission to use the swimming pool located at the campsite in Dickson, Tennessee.
Check Yes or No for Swim Release:
*
Yes - The camper has my permission to swim. If yes, you must sign the below release.
No - The camper does not have my permission to swim.
Signature Release to Swim (Must sign if "Yes" was checked):
Parents/Legal Guardian must sign if the camper is under 18 years of age.
Swim Release - Date of Signature:
*
-
Month
-
Day
Year
Statement of Certification and Understanding
Baptismal Release:
Water baptism is offered to campers during camp. We, the Church of God of Prophecy, teach baptism as an outward expression of our commitment to follow Christ and His example. This does not make a person a Christian or a member of the church.
Water Baptism Release Signature (Must sign if "Yes" was checked):
Parents/Legal Guardian must sign if the camper is under 18 years of age.
Water Baptism - Date of Signature:
*
-
Month
-
Day
Year
Statement of Certification and Understanding
Medical Conditions, Allergies, or Special Needs:
Medications (Please list medications taken on a regular basis)
Current Weight:
Blood Type:
Most recent tetanus shot:
Emergency Information
Insurance Company:
Insurance ID#:
Emergency Contact:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Consent:
In the case of an emergency, I understand that every effort will be made to contact me (parent/guardian). In the event I cannot be reached, I hereby give my permission to the camp director and physician selected by the camp to secure proper treatment for, to hospitalize, and to order injection, anesthesia, and/or surgery for the camper. I understand that if any accident or sickness should occur which is not covered by camp insurance, it is my responsibility and the camp will not be liable for any of the expenses incurred in such cases.
Signature for Medical Consent:
*
Parents/Legal Guardian must sign if the camper is under 18 years of age.
Medical Consent - Date of Signature:
*
-
Month
-
Day
Year
Statement of Certification and Understanding
I understand that I must make a deposit or full payment to secure my application. Clicking the payment button submits the application & takes me to the payment site.
*
I Am Paying a Deposit or In Full
My church Is Paying Tuition (Church must authorize)
Submit
Submit
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