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Permission statement and medical, surgical, liability waiver:


__________________________________ (child's name) has my permission to attend youth camp, and participate in all activities except as noted by me. He/she also has my permission to be transported by private automobile, driven by a responsible adult (no 16 year old drivers permitted) to any off-site activities. I understand that he/she will remain in camp for the full session, unless excused by the camp directors for medical reasons or family emergency. The camper will be under the supervision of camp personnel and is subject to camp regulations. In case of illness or injury, I approve of camp personnel taking my child/ward to the nearest medical facility for treatment. If any medical emergency should arise while my child/ward is at youth camp or in transit for swimming, and I cannot be reached, I give my permission for the Camp Directors to select a physician and/or hospital for my child/ward. I give the physician and/or hospital as selected by the Camp Directors or representative of the Youth Camp, my permission to hospitalize, treat, give x-rays, test and to order injections, anesthesia, or surgery for my child/ward who is named herein. I do release, acquit, discharge and covenant to hold harmless the Mt. Zion Baptist Assembly, and the ____________________________________ (name of church you attend). Parent/Guardian signature:____________________________________________________ Date:___________________

We will have silk-screened T’s for sale again this year, but they must be pre-ordered and pre-paid. These are optional, and cost an extra $9.00 in addition to your registration fee. Registration Options (please check all that apply): ___ I will attend Older Youth camp (grades 7-12) July 5-9; enclosed is my $40 registration fee ($50.00 if postmarked after June 25). ___ I will attend Younger Youth camp (grades 3-6) July 12-15; enclosed is my $35 registration fee ($45.00 if postmarked after June 25). ___ (Optional for ages 15 and up) Send me an application for being a Jr. Cabin Leader during younger youth camp. Please apply before June 15th! Tee-Shirt Option ___ Yes, I want a 2010 Mt. Zion T-shirt; enclosed is an additional $9.00. (No shirt orders after June 25) specify size (circle one): Youth sizes: medium large Adult sizes: small medium large x-large xxlarge MAIL FORM AND FEE TO CAMP REGISTRAR: LORI SHULTZ * 12601 ROUTE E * HARRISBURG, MO 65256

Mt. Zion Camp Registrar, LORI SHULTZ 12601 ROUTE E HARRISBURG MO 65256

Cost for older youth camp this year is $40 per person, younger youth camp is $35 (if you have finished sixth grade and are going into seventh, you can attend whichever camp you prefer - but you can NOT attend both). Registration deadline is June 25, 2010. Any registrations postmarked after June 25 will be charged an extra $10. Make checks payable to Mount Zion Assembly.

Daniel 3:17 Older Youth Camp

July 5-9 (Mon.-Fri.) Younger Youth Camp

July 12-15 (Mon.-Thur.)

Mt. Zion Youth camp form, 2010, pg 2  

This is to be printed on the back of pg 1, on 8 1/2x14 size paper.