Kids’ & Youth Camp 2011 •Monday, June 20 - Friday, June 24 •Monday, June 27 - Friday, July 1
Guest speakers: • Pastor Barb Barnhart, Youth Camp Monday, June 20 - Friday, June 24 * Entering grades 6 through 8 in the fall
• Pastor Chuck Thomas, Kids’ Camp Monday, June 27 - Friday, July 1 * Entering grades 3 through 5 in the fall
• Cost: $100 for first child; $85 for each additional child from the same immediate family Make checks payable to the Pittsburgh Conference Kids’ Camp & mail to: Randy Phillips 1347 1st Avenue Conway, PA 15027
Registration begins at 3:00 p.m. on the first day of camp.
• What should I bring to camp?
1027 Anderson Boulevard East Liverpool, Ohio 43920 www.tri-statefamilycamp.com
The 10 Commandments of Camp • You MUST take showers. (Due to certain activities, you will most likely get sweaty and dirty.) • Obey directions of camp leaders. • Wear shoes at ALL times. • All medications must be given to the camp nurse for distribution. • Wristbands MUST be worn at all times or you will be sent home. • You MUST stay with your coach when you are off camp property. • Boys and girls are NOT permitted in each others dorms. • Only those campers assigned to your room are permitted to be in there, unless your coach has two rooms and needs to use one for devotions. • There will be NO profanity used at camp. • There will be NO fighting while at camp.
• Registration forms postmarked by June 11 will receive a FREE t-shirt.
Tri-State Free Methodist Camp
* Please take note: There will be a skit and karaoke night during camp. If you have something that would be appropriate for these performances, you can bring it with you.
Bible, towels, washcloth, toiletries, pj’s, swimsuit, sleeping bag (bedding), pillow, clothes for rainy days, flashlight, fan, bug repellent, money for store & a good attitude * Special note to parents & guardians: Money should be kept in name tag holders for safe keeping.
• What should I leave at home?
CD player, radio, iPod, mp3 player, knives and other sharp objects, shaving cream, squirt gun, laser pointer, matches, lighter, tobacco, alcohol, drugs & cell phone. * If it is necessary for you to have a cell phone, it must be turned in to the camp director.
• I agree to abide by all of the camp rules & participate in the total camp program: ________________________________ (Camper signature)
• The camp director has the right to contact parents to pick up unruly children. * This camp is for all of God’s children regardless of gender, race, color or national origin.
Kids’ & Youth Camp Registration Form Personal information: [Please use the back of this form or securely attach another page to it for additional information, if necessary.] Allergies ____ Y ____ N Please explain: _______________________________________ _______________________________________ ______________________________________________________________________________________________________ _______________________________________ _______________________________________.
Do you have health insurance ____ Y ____ N
Name of insurance company ___________ _______________________________________
Name & dosage of any medications that must be taken _________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________.
Date of birth __________________________
Date of last Tetanus shot _______________
Name on policy _________________________
Age ______ Grade entering in fall ______
Contact lenses ____ Y ____ N
I will be attending ____ Kids’ Camp (grades 3-5) (June 27 - July 1) ____ Youth Camp (grades 6-8) (June 20 - June 24) Please list one (1) roommate preference:
Swimming or activity restrictions ____ Y ____ N Please explain: _________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________.
Name _________________________________ Gender ____ Male
Address _______________________________ City ______________________ State _______ Zip code __________ Church ____________ Phone number _________________________
Height ____________ Weight _________lbs.
Circle shirt size: Child S, M, L Adult S, M, L, XL, XXL
Do we have permission to treat your child with over-the-counter medications ____ Y ____ N Circle if permitted: Tylenol, Ibuprofen, Tums, Pepto-Bismol, Other ______________________
Health information: Pre-existing or current medical condition ____ Y ____ N Please explain: ______________ ____________________________________________ ____________________________________________ _____________________________________________ ____________________________________________.
* Please send or attach any additional information you think necessary in order for us to give your child proper medical care if they receive injuries or contract an illness during their time with us at camp.
If you have insurance, your carrier will be billed for medical charges in case of illness or injury while your child is at camp.
Policy number __________________________ Group number _________________________
Family doctor __________________________ Phone number _________________________
Emergency information: • Parent/Guardian _______________________ ________________________________________ Home phone # __________________________ Work phone # __________________________ Cell phone # ____________________________ • Alternate contact ______________________ ________________________________________ Home phone # __________________________ Work phone # __________________________ Cell phone # ____________________________
Medical & Liability Release Statement For: __________________________________ (Camper’s name)
• I understand that if medical intervention is needed, every attempt will be made to immediately contact the persons listed on the registration form. If I can not be reached in an emergency during the activity dates shown on the registration form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, secure medical treatment and/or order an injection, anesthesia or surgery for my child as deemed necessary. • I understand that my insurance coverage for my child will be used as primary coverage in the event that medical intervention is needed. Coverage by the Pittsburgh Conference Children’s Ministries accident policy will be used as a backup for what my family’s insurance does not cover. • I understand all reasonable safety precautions will be taken at all times by the Pittsburgh Conference Children’s Ministries and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold the Pittsburgh Conference Children’s Ministries, its leaders, employees and/or volunteer staff liable for damages, losses, diseases or injuries incurred by the subject of the registration form. ____________________________________ (Parent/Guardian Signature) Date:__________________________________