Camper Information

Today’s Date

Grade Completed Prior To Start of Camp

Name

Date of Birth

Gender

Male
Female

Phone Number

Address

Camp Registration Options

Available Camps

Sr High Camp ($180.00)
completed 9-12th grades - June 2-8
Jr High Camp ($180.00)
completed 6-8th grades - June 9-14
Kids Camp ($145.00)
completed 1st-5th grade - June 16-19

Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Email

Camper Medical Information

List any allergies of camper:

List any medications the camper is currently taking and dosage:

List any existing medical conditions of camper:

Camper Insurance Information

Insurance Company

Insurance Co Phone Number

Name of Policy Holder

Policy Number

Group Number

Medical Permissions and Liability Waiver

A signed medical/liabilty release by event participant or parent/guardian will be required for each registrant to attend camp. Please read the statements carefully below and sign.

OVER THE COUNTER MEDICINE PERMISSION -Do you give permission for your child to be given over-the-counter medication as needed & as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomach ache, or allergic reaction (i.e. Tylenol, Advil, Antacids, Benadryl, Hydrocortisone Cream, etc.) while attending camp?

Yes - I give permission for OTC meds
No-I do not give permission for OTC meds

MEDICAL RELEASE STATEMENT- I understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give permission to the camp staff, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. PLEASE SIGN BELOW TO GIVE PERMISSION FOR MEDICAL TREATMENT

Yes - I give permission for medical treatment
No - I do not give permission for medical treatment

MEDICAL RELEASE STATEMENT SIGNATURE

IN ADDITION, PLEASE SIGN BELOW TO ACKNOWLEDGE CONFIRMATION OF CHECK MARK ABOVE FOR MEDICAL TREATMENT PERMISSION.

I, the undersigned, agree to the terms above.

LIABILITY RELEASE AGREEMENT

LIABILITY RELEASE AGREEMENT: In consideration of KY State Church of God Ministries and Four Seasons Christian Center allowing the Participant to participate in summer camps, I, the undersigned, do hereby release, forever discharge and agree to hold harmless KY State Church of God Ministries and Four Seasons Christian Center, its pastors, directors, employees, volunteers and teachers from any and all liability, claims or demands for accidental 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 while involved in the youth activities. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in summer camp activities. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said KY State Church of God Ministries and Four Seasons Christian Center for any liability sustained by said KY State Church of God Ministries and Four Seasons Christian Center as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
PLEASE SIGN BELOW TO AGREE TO THE LIABILITY RELEASE AGREEMENT

I, the undersigned, agree to the terms above.

Church Information

Church Name

City or County of Church

Pastor's Name

Church Phone Number

Comments

Coupon Code

Camp	Dates	Director(s)	Early Registration (includes tshirt) by April 28th	Regular Registration until May 19th	Late & walk in registration After May 19th
Sr High (completed 9th-12th grades)	June 2-8	Wade Calvert & Aaron Gaunce	$180 w/ $50 nonrefundable deposit	$230 w/ $50 nonrefundable deposit	$280 w/ $50 nonrefundable deposit
Jr High (completed 6th-8th grades)	June 9-14	Taylor and Ruthanna Easterling	$180 w/ $50 nonrefundable deposit	$230 w/ $50 nonrefundable deposit	$280 w/ $50 nonrefundable deposit
Kids (completed 1st-5th grades)	June 16-19	Emily Kaskey	$145 w/ $50 nonrefundable deposit	$195 w/ $50 nonrefundable deposit	$245 w/ $50 nonrefundable deposit

Important Details

Location Information