Online Camp Application

Camper First Name *

Camper Last Name *

Male or Female *

Age *

Date of Birth *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Phone *

Phone number type *

Email Address

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone number *

Camper Shirt Size *

Desired Shirt Size *

Does the Camper have any Dietary Restrictions? *

Please List all Dietary Restrictions *

Does the Camper have any Allergies? (BeeStings, Penicillin, Peanuts, Fish, Gluten Free, Non-Dairy, etc.) *

Please List all Allergens. *

Does our Staff need to be aware of any Medical Conditions? (ADHD, Bi-Polar, Depression, I.E.P or 504 Plan, etc.) *

Please List any Medications or Accommodations our Nurse and Leadership Staff Need 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 your Camper should not participate in? *

Please specify the activities or any accommodations we can do to include them in activities. *

Does Your Family Have Health Insurance? *

Medical Insurance Provider. *

Phone *

Medical Insurance Group Number. *

Medical Insurance ID Number *

Primary Care Provider *

Primary Care Provider Phone number *

Medical Consent – I understand that if any accident or sickness should occur or is determined was transmitted during camp, which requires treatment emergency or otherwise, the campers private insurance will be considered the primary insurance. I understand that The Church of God of Prophecy Youth Camp, Camp Kairos, Camp Coordinators, Camp Directors, Camp Staff, Event Facility, and Facility Staff will not be held liable for any accident, sickness or expense relating to the any accident. In case of emergency, I understand that every effort will be made to contact the child’s Parent/Guardian, or Emergency Contact. If the Parent/Guardian, or Emergency Contact 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 (By checking this box, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, and agree to the terms of the attached Release and Waiver of Liability. I understand that checking this box represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) *

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. *

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 or by check to the address below. Please send all emails to Camp_Coordinator@campkairoswa.com *

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

Parent/Guardian Signature (By entering my name in the following boxes, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, agree to the terms of the attached Releases and Waivers of Liability. I understand that all the information I have entered on this application are honest and true to the best of my abilities. I understand that entering my name in the following boxes represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) *Agree

First Name *

Last Name *

Today's Date *

Month

Day

Year