Camp Kairos Applicaton Online

Online Camp Application

Male or Female *

Name Of Camper *

First

Last

Date Of Birth *

Date Of Birth

Age *

Home Address *

City *

State *

Zip Code *

Home Phone Number *

Cell Number *

Email *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Camp Attending *

Teen Camp (ages 13-19 / $195)
Pee Wee Camp (ages 5 - 7 / $95)
Jr Camp (ages 8 - 12 / $195)
Young Adult Camp (ages 18 - 30 something / $95)
Winter Teen Retreat (ages 13 - 19 / $95)

Please Specify Any Dietary Restrictions *

Please Specify Any Allergies *

Bee Stings, Penicillin, Peanut, Gluten Free etc...

Please List Any Medical Conditions The Camp Needs To Be Aware Of *

All medications are to be administered by the camp nurse for campers 18 years or younger. The camp nurse will collect all medications at the time of registration

Are there any activities the camper should not participate in? If so, please specify *

Does Your Family Have Health Insurance? *

Name & Address Of Medical Insurance *

Medical Insurance Contact Information *

Medical Insurance Group / ID Number *

Name & Contact Information Of Primary Care Physician *

Medical Consent - I understand that if any accident or sickness should occur which requires emergency treatment, the campers private insurance will be considered the primary insurance. I understsand that The Church of God of Prophecy Youth Camp, Directors and Staff will not be held liable for any accident, sickness or expense relating to the same. In case of emergency, I understand that every effort will be made to contact the child’s parent or guardian. If the parent or guardian cannot be reached, permission is hereby given to the camp staff and /or physician to secure proper treatment for and/or hospitalization and to administer injection, anesthesia, surgery and/or other emergency treatment deemed necessary for the minor child above. *

I Agree
I Disagree

COVID-19 CHURCH OF GOD OF PROPHECY GENERAL RELEASE OF LIABILITY - I (participant/parent or guardian of participant if a minor) acknowledge the extremely contagious nature of the worldwide pandemic, COVID-19, and that many federal, state, and local governments and health agencies have recommended protocols such as social distancing, temperature checks, and facial coverings. Camp Roganunda and Church of God of Prophecy – Washington & Alaska, Inc. cannot guarantee I will not become infected with COVID-19. I agree, represent, and warrant that I will not participate in the gathering held on the Camp Roganunda premises (Youth Camp or Teen Retreat), whether taking place inside or outside the premises, if I 1) experience symptoms of COVID- 19, or 2) have a suspected or diagnosed/confirmed case of COVID-19. I agree to notify Camp Roganunda immediately if I believe any of the foregoing use restrictions apply. I voluntarily assume the risk that I may be exposed to or infected by COVID-19 by participating in the Event and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID- 19 by participating in the Event may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Camp Roganunda employees, other contractors, volunteers, and other participants. I agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, I may experience or incur in connection with my participation in the Event. I release and forever hold harmless Camp Roganunda and Church of God of Prophecy – Washington & Alaska, Inc., its board, directors, officers, employees, agents, contractors and affiliates as well as the Released Parties from the claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree this release includes any claims based on the actions, omissions, negligence or gross negligence of Camp Roganunda and Church of God of Prophecy – Washington & Alaska, Inc., its board, directors, officers, employees, agents, contractors and affiliates, whether a COVID-19 infection occurs before, during, or after my participation in any Event. IN WITNESS WHEREOF each party hereto has executed this Waiver by its authorized signatory as of the day, month, and year indicated below, and the Waiver becomes effective upon the date of the last signature hereto. If Participant is a minor (under the age of 18), the signature of parent/guardian, below, is required. When signing/typing my name and dating this form it will be accepted as my signature.

I Agree
I Disagree

Release For Participation - I (we), the parents(s) or guardian(s) of the above listed minor grant permission for our minor to participate in all activities at Camp Kairos, this can include but not be limited to paintball and swimming. I (we) also release and agree to hold harmless Camp Kairos and The Church Of God Of Prophecy and all its participants from any liability and assume all risk of injury, damage or expenses as a result of participation in activities at Camp Kairos. In case of emergency, I give permission for the leadership of Camp Kairos to provide and/or arrange emergency care for my minor, and to arrange for transport to an emergency center for treatment if deemed neccessary. I grant consent to medical treatment deemed immediately necessary or advisable by a physician if I am unable to act on my minor's behalf. I further understand the Camp Kairos and The Church Of God Of Prophecy is not responsible for payment for such medical treatment. I also give permission for Camp Kairos to use any photo or video of my child for DBC publications or promotion/advertising. I release my right to any kind of remuneration for said photos or videos. *

I Agree
I Disagree

Camp Rules - I understand and agree that the camper will abide by all the rules, policies and discipline of the camp set forth by the director and staff. The rules & Policies can be found under the Parents tab on the main Camp Kairos web page. Any camper that engages is illegal activities, endangers others, or refuses to conform to the camp rules is subject to being sent home immediately. The parents or guardians will be responsible for transportation and will forfeit camp fees. *

I Agree

Water Baptism - I give my consent for the summer camper, if under the age of 18, to participate in water baptism? *

A minimum $25 deposit is required for camps and retreats unless previously agreed upon with our Camp Coordinators Corey & Michelle McBee. Deposits need to be paid or arranged for 1 week prior to the first day of the camp or retreat. Camp Fee's can be paid online https://campkairoswa.com/shop/ or by check to the address below. Please send all emails to Camp_Coordinator@campkairoswa.com *

I agree

Camp Fee's can be paid online https://campkairoswa.com/shop/ or by check. Please Make Checks payable to Church of God of Prophecy (COGOP). Mail camp fees to : Corey & Michelle McBee 1743 S Oakes St. Tacoma, WA 98405

If you have any requests, comments or special instructions (i.e. regarding payment, campers needs/wants, etc.) please leave those here.

Parent or Guardian Signature *

First

Last

Today's Date *