Summer Camp Detailed Registration Form

Summer Camp Registration
Our camps are available for those going into K - 6 grades. If a child is going into Grades 7+ or is between the ages of 3-4, please call the office for other options. Children are separated into three age groups: K - 1; 2 -3 & 4 - 6.
How many campers are attending?*
- Due to limited spacing, we are asking that you register your child/children for 1 camp ONLY. If your child/children will not be attending camp that week due to any unforeseen circumstance, please notify the Wayne-Pike Child Evangelism Fellowship office by email: wpcef1@gmail.com or call 570-253-6444, before the week of camp begins.
- Pike County Camp @ Milford Bible Church (July 6 - 10)Honesdale Camp @ Tabernacle Bible Church (July 13 - 16)Waymart Camp @ the Waymart Church (July 20 - 24)Carbondale Camp @ the Carbondale Church (July 27 - 31)
- Honesdale Camp @ Calkins Baptist Church: P/U @ 8:40 - 8:50am, Ret @ 4:05pmHonesdale Camp @ Honesdale Courthouse P/U @ 9:10-9:20am, Ret @ 3:40-3:50pmWaymart Camp @ Evergreen Elementary: P/U @ 8:40 - 8:50am, Ret @ 4:15pmWaymart Camp @ Canaan Bible Chapel: P/U @ 9:00-9:10am, Ret @ 3:50-4:00pmNO, my child will not be taking the bus.YES, my child is taking the bus; but not every day.
- MondayTuesdayWednesdayThursdayFriday
- Camper Information
- Camper's Name*
  
  First NameLast Name
- Birth Date*
  
  MonthDayYear
- MaleFemale
- Grade the camper is going into:*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Which school does the camper attend?
- Parent/Guardian Information
- Name*
  
  First NameLast Name
- Home Number*
  
  Area CodePhone Number
- Cell Number*
  
  Area CodePhone Number
- E-mail*
- Church affiliation
- Emergency Information
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
- Is the camper prescribed an inhaler? If yes, please explain any instructions.
- Camper Information
- Camper's Name
  
  First NameLast Name
- Birth Date
  
  MonthDayYear
- Grade the camper is going into:*
- MaleFemale
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Which school does the camper attend?
- Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
- Is the camper prescribed an inhaler? If yes, please explain any instructions.
- Camper Information
- Camper's Name*
  
  First NameLast Name
- Birth Date*
  
  MonthDayYear
- MaleFemale
- Grade the camper is going into:*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Which school does the camper attend?
- Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
- Is the camper prescribed an inhaler? If yes, please explain any instructions.
- Camper Information
- Camper's Name*
  
  First NameLast Name
- Birth Date*
  
  MonthDayYear
- Grade the camper is going into:*
- MaleFemale
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Which school does the camper attend?
- Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
- Is the camper prescribed an inhaler? If yes, please explain any instructions.
- Informed Consent and Acknowledgement
  
  I hereby give my approval for my child’s participation in any and all activities prepared by Wayne - Pike Child Evangelism Fellowship during the selected camp. In exchange for the acceptance of said child’s candidacy by Wayne - Pike Child Evangelism Fellowship. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Wayne-Pike Child Evangelism Fellowship. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.
  
  In case of injury to said child, I hereby waive all claims against Wayne-Pike Child Evangelism Fellowship. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
- COVID 19 Release
  
  This release and waiver between and/or amoung {nameParent}, the parent(s) and/or guardian(s) of {campersName} {campersName79} {campersName100} {campersName120} who resides at {address3} {address} {address104} {address124}(respectfully) with a phone number of {homeNumber} (H) ,{cellNumber} (C), hereinafter generally referred to a parent(s) and/or guardian(s)
  
  AND
  
  Child Evangelism of Eastern Pennsylvania, INC., a faith-based non-profit(non-stock) corporation, organized and doing business under the Laws of the Commonwealth of Pennsylvania, with its business located at 461 Grove St, Honesdale, PA 18431, hereinafter generally referred to as "CEF"
- COVID 19 Waiver
- Confirmation
  
  BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
- Signature
  
  Clear
- Medical Release and Authorization
  
  As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
  
  Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.
  
  Permission is also granted to the Wayne-Pike Child Evangelism Fellowship. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.
  
  Release authorized on the dates and/or duration of the registered season.
  
  This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
- Confirmation
  
  BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
- Signature*
  
  Clear
- Please review this image of the camp information.
- Click the button below to submit this form

Summer Camp Registration