Youth Camper Registration 2019
Youth Camper Registration 2019
Name  * 
Date of Birth  * 
Gender: Male / Female  * 
Address  * 
Phone  * 
What Church Are You With?  * 
Parent/Guardian Information
Father's Name  * 
Father's Phone #  * 
Father's Address (if different)
Mother's Name  * 
Mother's Phone #  * 
Mother's Address (if different)
Camp Information
Camp Reg is $120 ($150 after July 1st) | Family Discount (2+Kids) $110 (no discount after July 1st). You may pay Camp Reg fee in full, see drop down option.
Minimum Registration / Base Fee of $20 Required - *Pre-Registration Only (Non-Refundable)
Camper Checkout Information
Allowed to Check Camper Out (ex. Full Name & Relation)  * 
Allowed to Check Camper Out (ex. Full Name & Relation)  * 
Medical Information
Please indicate any medical problems that apply to the camper. If it is a current problem, please provide date of most recent occurrence: if past problem, give approximate date.
All medications will be given to and administered by the camp nurse, they MUST be in the original container.
Epilepsy | Asthma | Fainting | Diabetes | Heart | Kidney | Ivy, Oak, or Sumac Poisoning | Bees/Wasps  * 
If you answered "Yes" to any of the above, please give details and medication below. Including any restricted activities or foods. * 
Please list any additional problems or information that you feel Camp Staff should be aware of. * 
In the event of accident, injury, sickness, or any medical emergency, I understand that reasonable effort will be made by the camp staff to contact me (parent or guardian of camper). IF I AM NOT CONTACTED, I HEREBY GIVE PERMISSION TO THE CAMP DIRECTOR AND PHYSICIAN SELECTED TO SECURE PROPER TREATMENT FOR, TO HOSPITALIZE, AND ORDER INJECTION, ANESTHESIA, OR SURGERY FOR THE CAMPER.
Camp Policy: Before registering for camp all campers should be checked for head lice. All campers will be checked upon arriving at camp. NO campers will be allowed to stay at camp with head lice.
IMPORTANT: Camp applications cannot be processed unless this form is completed and signed. Please list the name of your insurance company (Hospital/Medical) and policy number. Camp insurance is secondary.
Name of Physician * 
Physician's Phone Number  * 
Name of Insurance  * 
Insurance Policy #  * 
I certify that all the information provided on the 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, its administration, and staff personnel.
Camper Name & Date  * 
Parent Name & Date  * 
In consideration for being accepted by The Pentecostal Church of God for participation in Youth Camp, I do hereby release forever discharge and agree to hold harmless The Pentecostal Church God and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above-described trip or activity including recreation and work activities. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.
I agree to statement listed above.  * 
Parent Name & Date  * 
Your Email Address  * 
Please type in the box to the right »  * 
Base Price $
Modifications $
Total $
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