Indiana District Camper Registration Form printable pdf download

All Previous Revisions Of This Application Are Unacceptable By Order Of The Indiana District Board

Rev. 2012

Indiana District

Camper Registration Form

Sunday School Camps

Youth Camps

o 8 & 9 yr old

o 10 & 11 yr old

o Teen Camp

o Conquerors Camp

Camp

Ages 12-14

Ages 15-18

Section 1 – Camper

o Male

Date of

Name:

Gender:

Age:

o Female

Birth:

Street Address:

Phone:

City:

State:

Zip Code:

Guardian

Please answer the following

Parent or

Email:

questions:

Guardian:

o Yes

Been

Received the

Pastor:

Repented?

Baptized?

Holy Ghost?

o No

I will abide by camp rules and dress code. I will be obedient and cooperative at all times.

(A list of rules is included on back of this form, or has been provided by the Pastor.)

has list of items to bring

Camper’s

Date:

Signature:

Bring your own Bible, toilet articles, and bedclothes (sheets, blanket, and pillows)

Section 2 – Parent or Guardian

Bus.

Name:

Phone:

City of Church :

Pastor:

The information below must be filled out and signed by the parent or guardian before a camper can register.

o Yes

Is camper on

Is the camper allergic

If yes, what?

medication?

to any medication?

o No

o Yes or o No

(If yes, camper must be checked by

In the past 14 days, has the camper been diagnosed or treated for head lice?

camp nurse before attending camp)

Does the camper have any physical defect or illness of which we should be aware?

o Yes or o No If yes, explain below:

I hereby grant my permission for the camper named above to receive necessary doctor and medical treatment, which

the camp nurses, or management deems necessary for his/her well-being. I agree to assume all responsibility for

expenses not covered by camp insurance.

NOTE: Parents will be held responsible for the cost of any damage created by the camper. Parents will also be responsible

to provide transportation home early if a camper is dismissed for misbehavior. Transportation must also be arranged for

picking up the camper and leaving the campgrounds no later than 11:00 p.m. on the Friday night of the camp attended.

Parent or Guardian

Date:

Signature:

Section 3 – Pastor (NOTE: No camper will be registered without an UPCI Pastor’s signature)

I, ____________________________________(Print)

Pastor of ___________________________________________

Pastor’s name

Camper’s name

have advised this applicant of all camp rules and his/her obligation to abide by them. I hereby pledge to uphold the

camp in all of the camp policy.

Pastor’s

Date:

Signature:

(NOTE: Pastor’s signature signifies that he has read the completed camp registration form and will recommend this

camper. A camper from a non-UPCI church must have the signature of the nearest UPCI pastor.)

Camp registration fee:

Enclose fee with completed registration form and mail to:

SS Camps -Rev. Steve Addison, 504 W. 8th St.

$150.00

pre-registration (postmarked by 1 week before Camp)

Rochester, IN 46975 (765) 419-1918

$165.00 (after pre-registration deadline)

Youth Camps -Rev. Jeremy Moore, 5333 E. Esche Dr.

Newburg IN 47630 812-568-8347

Make Checks payable to: Indiana District UPCI

Indiana District Camper Registration Form

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