Camper / Youth Worker / CIT Registration & Health / Consent Form

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June 17th - 21, 2024 Registration deadline is Friday, May 18th, 2024

Campers age: 7-13

Youth Workers age: 14-15

Counselor in Training (CIT) age: 16-17

Camp cost is $175 per camper

Please complete 1 form PER CAMPER

Email *

I understand that I will have to pay $175 to my local church. *

Yes, I understand

Required

Attendee's Name *

I am a: *

Camper (7-13)

Youth Worker (14-15)

CIT (16-17)

Parent / Guardian Name(s) *

Address *

Phone Number *

Date of Birth *

YYYY

Child's Age *

Last Grade Completed *

Gender *

Male

Female

Home Church / Pastor's Name *

Youth Worker / CITs, You are required to provide a letter of endorsement from your Church Pastor for consideration, this must include statements regarding: your Character, your witness, your stewardship and your relationship with God. You must email this to: jslater@rougefwbchurch.com *

I am able, and agree to provide a positive letter from my Church Pastor prior to camp

I am unable to provide a positive letter from my Church Pastor

Has your child made a profession of Faith? *

Yes

Maybe

T-shirt Size (shirts run true to size) *

Youth S

Youth M

Youth L

Youth XL

Adult S

Adult M

Adult L

Adult XL

Adult XXL

Adult XXXL

Allergies / Reactions *

Medical Conditions *

I will complete a head lice inspection on my child prior to arrival at camp *

Yes

Current / Recent exposure to Contagious / Infectious Disease? *

Yes

My child has been immunized against the following in accordance with HEW standards: Polio, Whooping Cough, Measles, Mumps, Rubella, Tetanus, Covid-19 *

Yes

Yes, except COVID-19

If no to previous answer, please explain. We may request supporting documentation.

Date of last Tetanus *

YYYY

List of Medications, Dosage, and frequency.

All prescribed medications must be labeled with licensed pharmacy and name of pharmacy and camper name.

All medications must be in original container(s) in a resealable bag marked with campers name and Date of Birth.

It is recommended to bring two (2) inhalers / epi-pens if prescribed to camper.

Camper restrictions (swimming, excersise, etc.) *

Dietary restrictions *

None

Vegetarian

Vegan

Kosher

Gluten-free

Other:

Insurance info: (Insurance Carrier / Policy Number / Phone number) *

Family Doctor Name & Phone Number *

Emergency Contact Names & Numbers *

By e-signing / typing my name below, I affirm:

I am the Legal Parent / Guardian for this child and I give consent for them to participate in the Liberty Association Youth Camp.

I hereby give consent in advance to the Camp Director, Program Director or Camp Medical Officer of Liberty Association Youth Camp and to the Physicians or medical facility selected by them to render first aid treatment, as in their judgment, is reasonably necessary, but not limited to: Hospitalization, diagnosis including taking specimens and x-rays, giving blood transfusions and medications, anesthesia, and surgery for my child. I understand the Camp Director, Program Director, or Camp Medical Officer will attempt to contact me before securing medical treatment, but that this consent is given in the event I am no available in an emergency. I release Liberty Association Youth Camp leaders and staff from any and all claims, loss, cost, damage, or expense arising out of or from any accident or other occurrences causing injury to any person or property.

A copy of your responses will be emailed to the address you provided.

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