Kids and Teen Camp Registration

TEEN:  June 24-28 (Ages 12-19)  Cost:  $245  
Registration and deposit ($50) due May 2.  
Final Payment ($195) due June 16

 KIDS:  July 15-18 (ages 8-11)  Cost: $230
Registration and Deposit $50 due May 2
Final Payment $180 due June 16
 

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* 1. Camper's Legal Name

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* 2. Name  Camper goes by (if different from above)

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* 3. Camp of interest

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* 4. Gender

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* 5. Age of camper

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* 6. Birthdate

Date / Time

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* 7. Address

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* 8. Parent/Guardian Name

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* 9. Contact Information

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* 10. Alternative Phone

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* 11. Which Life Church Campus are you registering with? 

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* 12. Desired Roommates (Some rooms may require sleeping on a mattress on the floor)

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* 13. THIS SECTION MUST BE FILLED OUT COMPLETELY

This health questionnaire is for the benefit of the camp first-aid administrator and physician in case of illness or accident. Camp registration includes secondary accident insurance (not illness) during camp. (This insurance covers campers only in the event they are not covered by another policy.)

I HAVE MEDICAL INSURANCE FOR MY CHILD

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* 14. Policy Number

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* 15. Name of Primary Insured 

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* 16. Insurance Company

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* 17. Are all immunizations current with state law?

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* 18. My camper may be given over-the-counter, non-prescription medications or applications, not to exceed recommended dosage, for stomach discomfort, burns, cuts, insect bites, rash, aches, fever, cough, congestion, etc.:

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* 19. Does Camper Have

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* 20. I understand that I must provide any medications for my camper in THE ORIGINAL BOTTLE as well as a dosage/times or allergies detailed list for the camp first-aid attendant.  I authorize the Camp Staff to administer my child's prescription medication according to the schedule I provide.  I give permission to the Camp Staff to secure and administer treatment, including hospitalization, for my child.  In the event that I cannot be reached in an emergency, I authorize Camp Staff to sign on my behalf, permitting my child to be treated and I agree to be financially responsible for treatment. 

Food Allergies:  I understand that the camp will not provide special meals for food allergies, but will provide a refrigerator and microwave in the kitchen so he/she can bring food if necessary.  I can obtain a cafeteria menu by emailing the youth department at iym@indianaag.org after May 1. 

I understand and give consent that all photos/video taken during camp may be used for promotional materials and publications.  In addition, I give permission for my child to participate in all camp-related activities including, but not limited to, swimming, zip line, archery, and the jet ski.  If my child is not allowed to participate in a particular activity, I must write a note to be given to staff at registration at camp.  

(Signature of Legal Parent or Guardian and relationship to this child required. Typing your name here serves as your digital signature for this registration.)

In submitting an application, all campers agree to abide by all camp rules, maintaining a Christian spirit of cooperation at all times.

*Digital Signature

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* 21. Add a Camp T-shirt? $12 if paid with registration.  $15 after May 2.

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* 22. Payment information
$50 registration fee due May 2
  Remainder due June 16  
*may pay entire amount with registration*



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