Clone of Camp Registration Form

Worker Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Worker E-mail

example@example.com

Mobile Number

Format: (000) 000-0000.

Parent/Guardian Name (if under 18)

First NameLast Name

Parent Mobile Number

Format: (000) 000-0000.

Work Number

Format: (000) 000-0000.

Church Name

Pastor Name

Are you currently taking any medication?

If yes to above, please list all medications worker is currently taking including administration instructions: (Please send all meds in original pharmacy containers in a clear bag with name)

Are there any illnesses, disease, or special medical circumstances that we need to know about the worker? If worker is currently under doctor's care, please list physician information in case of emergency.

Does worker have any of the following?

Does worker have medical insurance? Please type yes or no. If yes, please list current insurance information.

Emergency contact name & phone number

What area do you plan to serve?

For the safety and protection of all campers, all workers and volunteers age 18 and older are required to successfully complete a background check prior to serving at camp. A background screening authorization form will be sent to you before camp and must be completed in full. Failure to complete the authorization form will result in disqualification from serving as a worker or volunteer. The background check will be conducted solely for the purpose of evaluating eligibility to serve and will not include a credit check. All information obtained will be kept confidential and reviewed only by authorized leadership. Completion of the background check does not guarantee approval to serve. District leadership reserves the right to determine eligibility based on screening results. By typing the statement below, you acknowledge and agree to submit to a background check as a condition of serving: “I agree to submit to a background check.”

Media Release: I give permission for Twin States PCG to photograph and/or record me during camp activities. I understand these may be used for promotional purposes, including social media, website, and print materials, without compensation.

Additional Comments

The undersigned participant and his/her parent/legal guardian agree to hold Twin States PCG its employees, officers, and volunteers, from any claims, damages, losses, and/or expenses arising out of participation in camp activities and to assume all liability for any and all personal injury, bodily injury, illness, or property damage that occurs as a result of participation in such activities. Signature of this agreement also warrants that participation in this camp is voluntary and that the participant and undersigned understand the inherent risks involved in the camp’s activities. The participant understands that these risks exist despite the camp’s safety precautions and procedures and the participant agrees to obey all rules and policies mandated by camp personnel. The undersigned participant and his/her parent/legal guardian warrant that he participant is physically fit and able to participate in all camp activities and that there is and will be adequate health insurance coverage in force for the term of the camper’s attendance. The undersigned further verifies that the health insurance covers any and all accidents, injuries or illnesses that may result from participation in the camp activities and that the camp’s medical form has been completed, signed, and dated. The undersigned participant and his/her parent/legal guardian give the Twin States PCG and its representatives permission to provide emergency medical response and/or treatment as needed for any injury or illness that may occur while the participant is involved in camp activities and agree to release the Twin States PCG and its representatives from all liability arising out of such treatment. In addition, as the participant’s parent/legal guardian, I hereby give the undersigned participant permission to participate in any and all district approved camp activities either on or off the campgrounds.

By typing your name below, you are agreeing to follow the above camp rules. You certify that all information given is correct and complete.

First NameLast Name

Parent/ Legal Guardian Full Name & relationship to worker (if under 18):

WORKER AGREEMENT: I AGREE TO OBEY ALL CAMP RULES AND REGULATIONS WHILE ENROLLED AT CAMP.

Date

Worker fees will be covered this year! Please note, t-shirts are additional. We cannot guarantee shirt availability after the order date. Please be sure to get you orders in before 6/1/26. If you would like a t-shirt, please enter your size & payment below or to pay in person, please list your shirt order in the blank below:

To order tshirt & pay online, select below:

Adult Camp Tshirt

$25.00 Size

Total

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info

Twin States PCG Youth Camp Registration Form - Worker

To order tshirt & pay online, select below:

Payment Methods