High Rock Application Pre - Teen Week
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Email *
Camper's First Name *
Camper's Last Name
Home Address *
City *
State *
Zip Code *
Camper Email Address
Gender *
Required
Date of Birth *
MM
/
DD
/
YYYY
Age *
Home Congregation *
Member? *
Are you a member of this congregation?
Required
T-shirt size *
Preferred Cabin *
We will do our best to fulfill cabin requests, but cannot guarantee requests.
Emergency Contact Name *
Emergency Contact Phone Number *
xxx-xxx-xxxx
Family Physician *
First and Last Name
Family Physician's Phone Number *
xxx-xxx-xxxx
Medical Insurance Company *
Policy/Plan # *
Date of last Tetanus Shot *
MM
/
DD
/
YYYY
Allergies? *
Is your child allergic to anything?
Required
If so, What?
Leave blank if answer to above question is no.
Allergies
Medical Conditions? *
Does your child have any medical condition that may require special attention?  (example:  Diabetes, etc.)
Required
If so, What?
Leave blank if answer to above question is no.
Medical Conditions
Medications *
Please Check which Medications can be Administered-If Your child requires any medication other than the ones listed below, we need to have a prescription (even if it is an over the counter medicine.)

All medicine brought to the camp needs to be in its original container

All medications will be given to the camp nurse at registration time and they will be administered by the camp nurse.-If your child requires medication while at camp, please bring a letter of explanation when checking in on the first day of camp.
Required
Current Medications *
All medicine brought to the camp needs to be in its original container.

Please list all current medications, including over the counter that your child is currently taking.  If your child is not taking any medications please put NONE.
Parent Agreement *
By clicking on this box you are indicating that you have read and agree to the AGREEMENT WITH PARENT OR GUARDIAN.                                                                                                                                                                                                          AGREEMENT WITH PARENT OR GUARDIAN: It is necessary for parents to assume responsibility for the applicant, and for adult campers to assume responsibility for themselves. Below is a legal agreement for this purpose which you should sign and return with the application.  “In consideration of the acceptance of the named applicant, I, the undersigned parent, or guardian, or adult applicate as the case may be, covenant and agree with the High Rock Bible Camp Board of Directors, which meets in Elizabethton Tennessee, that I will at all times hereafter indemnify, keep indemnified, and hold harmless the said High Rock Bible Camp, and its Board of Directors and Staff, for any and all liabilities/claims/demands which I must pay, sustain, or incur as a result of illness, accident or misadventure to the named applicant, during the period that said applicant is a participant in the High Rock Bible Camp which is located in Duffield, VA.” This agreement, and all terms and conditions here in, shall be governed by Tennessee law.
Required
Photo/Video Release *
I hereby assign and grant High Rock Bible Camp on behalf of myself and on behalf of my child permission to use and publish photographs and video recordings taken of my child during any week of High Rock Bible Camp for use in printed publications, audio visual media, social media and the camp website. I hereby release High Rock Bible Camp from any and all liability from such use and publication.
Required
Parent or Guardian Name *
Parent or Guardian Phone Number *
xxx-xxx-xxxx
Parent Email Address *
Check In/Out *
Name of Those Able to Check Camper In/Out.  Please separate names by commas.
Application Submission Agreement *
By clicking on this box you are indicating that you have read and agree to the Application Submission Agreement and agree to the following:  "In the event of illness or injury, I hereby give my permission to the physician or hospital selected by the personnel of High Rock Bible Camp to secure medical treatment, or to hospitalize, prescribe medication, administer anesthesia, and perform any surgical procedures for the treatment of my minor child.”
Required
A copy of your responses will be emailed to the address you provided.
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