Male or Female * Male Female Age * Home Address * City * State * Zip Code * Home Phone Number * Cell Number * Email * Emergency Contact Phone Number * Please Specify Any Dietary Restrictions * Are there any activities the camper should not participate in? If so, please specify * Does Your Family Have Health Insurance? * Yes No 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. * 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. 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. * 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? * Yes No A minimum $25 deposit is required for summer camps. Deposit needs to be paid on or before June 27th. Camp Fee's can be paid online https://campkairoswa.com/shop/ or by check to the address below *
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
Parent or Guardian Signature * Today's Date *