2008 Heartland Summer Camp Registration

CAMPS
SR. High Camp * June 23rd - June 27th * (Grades 9-12)
Early Bird Deadline: June 6 * Registration Deadline: June 13
JR. High Camp * July 7th - 11th * (Grades 6-8)
Early Bird Deadline: June 20 * Registration Deadline: June 27
Kids' Camp * July 21st - 25th * (Grades 3-5)
Early Bird Deadline: July 8 * Registration Deadline: July 15
  Youth Camp X * July 7th - 11th * (Grades 8-12)
Early Bird Deadline: June 20 * Registration Deadline: June 27
Discipleship
Ministry
OutReach
(Select one Youth Camp X above)
 
Registration Fee: $204 [online/one child] $199 [family discount]
Early Bird Special: $194 [online/one child] $189 [family discount]

Fees are non-refundable, but are transferable only within 2008 Kids/Youth Camps.

Family Discount: The discount is for families with more than one camper (siblings) attending any of the camps listed on this form and applies to each camper. A completed registration form must be submitted for each camper participating in the discount plan.
 
Optional Items
CAMP VIDEO ($12.00)
T-SHIRT ($10.00)
Size:
 
LAST NAME:
FIRST NAME:
AGE:
SEX:
(Fall 2008) GRADE:
ADDRESS:
CITY:
STATE:
ZIP:
HOME PHONE:
CELL PHONE:
ALTERNATE PHONE:
 
CHURCH NAME:
CHURCH CITY:
PASTOR/LEADER:
 
I would like to room with (student/church & city):
STUDENT'S E-MAIL (YOUTH ONLY):
PARENT'S E-MAIL:


CAMPER HEALTH STATEMENT

Bronchitis:
If Yes, Approximate Date (mm/dd/yyyy):
Frequent
Colds:
If Yes, Approximate Date (mm/dd/yyyy):
Frequent
Sore Throat:
If Yes, Approximate Date (mm/dd/yyyy):
Abscessed
Ears:
If Yes, Approximate Date (mm/dd/yyyy):
Serious Ivy,
Oak or others:
If Yes, Approximate Date (mm/dd/yyyy):
Stomach
upsets:
If Yes, Approximate Date (mm/dd/yyyy):
Fainting:
If Yes, Approximate Date (mm/dd/yyyy):

Is camper,
overly sensitive to bug bites?
If so, what type?
 
Allergy?
 
Allergic Reactions: Bee Sting? Yes No
Penicillin? Yes No
 
Tetanus Booster? Yes No
Approximate Date?
 
Is camper receiving any medication at present?
Yes No

Will camper have medication with him/her?
Yes No 		If so,
please list and give details?

ALL PRESCRIPTION DRUGS MUST BE BROUGHT IN THE ORIGINAL CONTAINERS (WITH MEDICAL ORDERS AND PHYSICIAN'S NAME INTACT).  OTHERS ARE UNACCEPTABLE.
 
Explain necessary precautions needed to aid the camper and/or any other information that will assist in the care of your child.
 
Has your child had severe emotional problems in the past 12 months?
Yes No 		If yes, please explain:
 
Are there any learning problems that we should know about?
Yes No 		If yes, please describe:
 
Is the camper known to be a carrier of any contagious disease or virus?
Yes No 		If yes, please explain:
 
Are there restrictions as to someone picking up your camper?
Yes No 		If so, who?
 
PLEASE NOTE: In case of medical treatment, and/or expense, your personal medical coverage will be the primary carrier. The Ohio District Council Insurance will be secondary to your personal coverage.
 
Primary Insurance Carrier:
INSURANCE PHONE:
 
AUTHORIZATION RELEASE/DISCIPLINARY CLAUSE

I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered camper at any Ohio Assemblies of God Summer Camp, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said Camp to consent to any X-ray, examination, anesthetic, medical or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state of Ohio, when such medical or surgical treatment in necessary. I am aware that the administration of non-prescription medicines (Tylenol, anti-acid, etc.) may be necessary. I willfully consent for my child to receive these if deemed necessary.

No radios, tape players, CD players, pagers, cellular phones, or fireworks are allowed on the campground. No smoking, drinking of alcoholic beverages, or profanity is allowed on campground. We reserve the right to inspect the contents of all personal belongings at any time. The confiscation and/or disposal of improper contents is to the discretion of the Heartland CRC Camp Staff.

In case of dismissal due to voluntary withdrawal or disciplinary actions, there will be no refund of camp fees. I fully understand that failure to abide by camp policy may lead to my being sent home. I understand that telephones are not available for campers use. In case of emergency, camp staff will notify the parent or legal guardian. FOR EMERGENCIES ONLY, CAMP DIRECTORS CAN BE REACHED AT 740-747-0220. In case of illness, injury or death in the family, a pro-rated refund may be made for the unused term. All refunds must be approved by the Camp Director. All camp safety measures will be met. The camp or camp staff will not be held liable for accidents.

I understand that any pictures taken of campers while attending camp will become the property of Ohio District Council, and may be used for purposes of promoting Heartland Kids Kamps and/or Youth camps.

We have read, understand and will comply with the HCRC Pool Rules by initialing here.

For Outreach Camp at Camp X only: Due to the nature of this camp, it will be necessary to transport your student on and off the campgrounds each day of the camp. By initialing, you are granting us permission to use procured adequate and appropriate transportation for your child.

 
This registration is not complete without the following information signed by the camper and legal guardian/parent.

Typing your name in the box below serves as your signature agreeing that as a legal guardian/parent of the camper listed on this registration, you are responsible for the general conduct of the camper and will be responsible for any damages incurred.

Signed:
(Legal Guardian/Parent Signature)
 Date

Signed:
(Camper Signature)
 
Are you claiming the Family Discount* for this camper?

Yes No 		*The Family Discount option only applies to each camper for Family's of TWO or MORE campers, (immediate family members ONLY (i.e. siblings), attending summer camp. This is subject to verification by camp officials and you will be charged additional if claiming this discount in error! Please list the name of your sibling(s) and the camp(s) they will attend below which you will also be submitting an online camp registration for. (i.e. Johnny Doe (Jr High))
 
   OR   

Ohio District Council, Inc. of the Assemblies of God
8405 Pulsar Place, Columbus, Ohio 43240
phone 614.396.0700, fax 614.396.0701