2024 WV(DOC) Youth Summer Camp Registration Form

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* 1. Camper Contact Information

Last Name

First Name

Congregation- (if FCC please list City)

Address

City/Town

State/Province

ZIP/Postal Code

Age

Email Address

Phone Number

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* 2. The camper is:

Male at birth, Identifies Male

Female at birth, Identifies Female

Male at birth, Identifies Female

Female at birth, Identifies Male

Male at birth, Identifies as other

Female at birth, Identifies as other

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* 3. The camper will be attending:

Kids Camp June 9th -14th (Designed for K-2 grades)

Junior Camp June 9th-14th (Designed for 3-5 grades)

Chi Rho Camp June 9th-14th (Designed for 6-8 grades)

CYF at Bethany College

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* 4. Grade Camper is currently enrolled in or will be completing May/June 2024

kindergarten

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Counselor

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* 5. Parent/Guardian Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 6. The camper has a history of infection of:

Nose

Throat

Ears

Sinus

Lungs

Other (please specify)

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* 7. The camper is currently in good health

Yes

No-But noncontagious

No-Currently Contagious

Please comment further if checkmarked “No”

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* 8. Does the camper have any conditions requiring restricted activity?

Yes

If “Yes” please explain further.

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* 9. Is appendix present?

Yes

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* 10. Camper is subject to:

Sleepwalking

Convulsions

Asthma

Fainting

Hernia

Skin rashes

Mood disorders

Hyperactivity

Attention Deficit

Further explanation:

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* 11. Camper suffers from the following allergies

Peanuts

Tree nuts

Gluten

Bee stings

Medications

Other foods

Other allergies described in comment field below:

Please describe reactions & treatments:

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* 12. Camper is currently on the following medications:

Name, Dosage

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* 13. COVID vaccination status of camper

Unvaccinated

Vaccinated, up to date

If needs explanation, please provide here:

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* 14. Camper is up to date on all Public School Immunization Requirements

Yes

If no, please elaborate:

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* 15. Camper has received the flu vaccine in the past 6 months

Yes

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* 16. What is the camper’s swimming ability

Beginner

Intermediate

Advanced

Nonswimmer

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* 17. If you have a housing request, please provide the information here:

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* 18. Camper’s Family Doctor

Name

Phone Number

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* 19. Please provide 3 emergency contacts and phone numbers:

Name & Phone #

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* 20. In the event of illness or accident, I give permission to the Regional Minister/Camping Staff, and to the physician selected by the staff to secure proper treatment for, to hospitalize and to order, inject, anesthesia or surgery for the camper named above.

Yes

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* 21. Camper T-shirt Size

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XLarge

Adult XXlarge

Adult XXXlarge

AdultXXXXlarge

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* 22. The camper & Parent/Guardian agrees to this camp covenant: To come to camp expecting to grow in faith and in relationship with others, becoming a special part of the camp community. In order to do this, the camper covets to follow all the rules and guidelines set by the Christian Church Disciples of Christ in WV. The camper will attend and be attentive and participate fully. The camper will respect all present, cooperate with counselors, and take time to learn about God and share with their friends, family and church.

Yes

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* 23. The camp fee will be paid for by:

Me. Please use my email to invoice me to pay by credit card.

The church.

Cash/Check will be brought when arriving at the event.

Arrangements have been made through the regional ffice.

I am unsure. Please contact me to discuss arrangements.

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* 1. Camper Contact Information

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* 2. The camper is:

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* 3. The camper will be attending:

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* 4. Grade Camper is currently enrolled in or will be completing May/June 2024

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* 5. Parent/Guardian Information

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* 6. The camper has a history of infection of:

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* 7. The camper is currently in good health

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* 8. Does the camper have any conditions requiring restricted activity?

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* 9. Is appendix present?

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* 10. Camper is subject to:

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* 11. Camper suffers from the following allergies

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* 12. Camper is currently on the following medications:

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* 13. COVID vaccination status of camper

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* 14. Camper is up to date on all Public School Immunization Requirements

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* 15. Camper has received the flu vaccine in the past 6 months

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* 16. What is the camper’s swimming ability

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* 17. If you have a housing request, please provide the information here:

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* 18. Camper’s Family Doctor

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* 19. Please provide 3 emergency contacts and phone numbers:

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* 20. In the event of illness or accident, I give permission to the Regional Minister/Camping Staff, and to the physician selected by the staff to secure proper treatment for, to hospitalize and to order, inject, anesthesia or surgery for the camper named above.

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* 21. Camper T-shirt Size

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* 23. The camp fee will be paid for by:

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* 24. Additional information you would like us to know: