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Registration fee: Jr. High Camp $20 High School Camp $30 2011 Northeast Region Summer Youth Camp

Camper Info: Check one: _____High School Camp ________Jr. High Camp Name ______________________________ Sex_______________ Address___________________________________ Zip__________ City__________________________________ state______________ Age____________ Grade________________ Phone (______)___________________ Local church Youth Coordinator Signature___________________________________ Pastor, Lay Missioner, or Lay Speaker Signature______________________________ Contact Info: Emergency Contact Name __________________________________________ Relationship___________________________Phone(______)________________ Any Other Instructions_______________________________________________ Medical History___________________________________________________ Has or is subject to:(check if yes) _____Asthma

______Fainting Spells




_______Heart Problems

_________________Reaction to medication

if yes list____________________

Please list any allergies__________________________________

Has difficulty with (Check if yes) ______Eyes/ears/nose/throat



___________Lungs Any Condition require regular medication? ____________________________________ Name of medication_________________________Dosage____________________ Any restrictions of activity for medical reasons?_______________________________ ___________________________________________________________________ Insurance Company ______________________________________________ Policy________________________________________________________ Insurance Company Address_____________________________________________ Insurer's Name________________________SS#__________________________ Youth SS#_________________________DOB__________________________ Doctor’s Name___________________Phone____________________________

I hereby certify that the above information is correct and complete to the best of my knowledge, and the person herein described has permission to engage in all prescribed activities, except as noted above. The adult supervisors of____________________may authorize any and all medical treatment without liability.

_________________________________________ Parent/Guardian Signature

___________________ Date

I,_________________________________agree to abide by the rules of conduct as determined by the Northeast Region Youth Ministries and the staff of the Northeast Region Youth Camp. I, the parent(s)/guardian of, _____________________do hereby consent that she/he will follow all the rules and regulations as determined by the camp. I will not hold the Oklahoma Indian Missionary Conference, local churches, or any individuals responsible for any injuries or accidents that occur on the campgrounds, travel to and from the campgrounds, or during any activities outside of the campgrounds.

Signature of the Participant____________________________________________

Signature of Parent/Guardian__________________________________________

Oklahoma Indian Missionary Conference Guidelines for Conference Related Events I Covenant to..... 1. Put God first in my actions, thoughts, and decisions. 2. Set aside time each day to reflect and pray. 3. refrain from using chemicals of any type including tobacco. i will not have fireworks, firearms, knives, or any destructive weapons. 4. Be where I am scheduled to be at appropriate times. 5. Participate, with enthusiasm, in all activities planned, as I know I am an example for others and am representing God, my Family, My church and my conference. 6. Refrain from using inappropriate language while on this event. 7. Have a great week; be an encourager and take great ideas back home to share. 8. Always use a “buddy system.� travel in groups of 3, at least. 9. Do not leave designated areas without proper adult permission. 10. I agree not to bring any electronic devices, such as radios, Cd's, games, Ipods, cell phones, etc. 11. No alcoholic beverages, drugs, firearms, fireworks, guns, knives, or tobacco. 12. All medication should be turned into the designated medical person. 13. Any participant who does not adhere to the covenant and/or guidelines will be sent home at parent’s expense. 14. Participants who drive to camp must relinquish keys to the dean until the completion of the event. 15. I understand that there will be no late or walk-in registration once the deadline has been set. 16. Participant and parent/guardian must sign registration. 17. OIMC is not responsible for any thefts.



Participant Signature




Parent/Guardian Signature


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