Youth Camp Registration (Camper)

Camp Registration Form
Student's Name*

First Name / Primer NombreLast Name / Apellido
Student Details

Please fill out the details for student
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Student's Gender*

Female / HembraMale / Varon
Student's Medical Information*
Student's Guardian Name*

First NameLast Name
Student's Guardian Phone Number*
Please enter a valid phone number.
Student's Guardian Email*
example@example.com
Student's Age / Edad de campista*
Select One / Elige uno*

Female / HembraMale / Varon
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father / Guardian Name*

First NameLast Name
Mother / Guardian Name*

First NameLast Name
Parent / Guardian Phone Number*
Please enter a valid phone number.
Guardian's Email / Correo electronico de padres*
example@example.com
Alternative Phone Number (Emergency Contact)
Please enter a valid phone number.

Church Information

please fill out your church information
Name of local church you attend?
Pastor's Name/ Nombre de Pastor

First NameLast Name
Youth Leader's Name / Nombre de lider de jovenes

First NameLast Name
Youth leader's email / Correo electronico de director de jovenes
example@example.com

Camper Agreement / Acuerdo de campista
As a camper of the Church of God Youth Camp, I agree to abide by the rules and policies of the camp during my stay at camp. I understand that any deliberate breach of conduct or disregard of camp rules will necessitate disciplinary action, even to the extent of being asked to leave the camp. I understand that the Church of God Southeastern Hispanic Youth Camp is a private Church and Christian camp. I agree to conduct myself according to the principles and biblical beliefs of the Church of God during my participation at the camp. Any conduct which violates these principles and beliefs may be grounds for my dismissal from the camp, the transportation and other costs of which will be my responsibility. The camp administration retains full and sole discretion to dismiss me from the camp, for any reason it deems necessary.

Como campista del Campamento Juvenil de la Iglesia de Dios, acepto cumplir con las reglas y políticas del campamento durante mi estadía. Entiendo que cualquier incumplimiento deliberado de conducta o desobediencia a las reglas del campamento requerirá acción disciplinaria, incluso hasta el punto de que se me pida retirarme del campamento.

Entiendo que el Campamento Juvenil de la Iglesia de Region Surestes Hispana una iglesia privada y un campamento cristiano. Acepto conducirme de acuerdo con los principios y las creencias bíblicas de la Iglesia de Dios durante mi participación en el campamento. Cualquier conducta que viole estos principios y creencias podrá ser motivo de mi expulsión del campamento, cuyos gastos de transporte u otros costos serán mi responsabilidad.

La administración del campamento se reserva la plena y exclusiva discreción de expulsarme del campamento por cualquier motivo que considere necesario
Camper's name / Nombre del campista

First NameLast Name
Camper's signature / Firma del campista

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Medical Information

A parent / Guardian must complete this section. Un padre/madre o tutor legal debe completar esta sección.
Please answer whether or not the following may be administered to your child, if needed, while at camp. You do not need to bring these since these medications are available at camp.*

Por favor indique si los siguientes medicamentos pueden administrarse a su hijo(a), si es necesario, mientras esté en el campamento. No es necesario que los traiga, ya que estos medicamentos están disponibles en el campamento.
Acetaminophen (compared to active ingredient in Tylenol)*
Ibuprofen (compared to active ingredient in Advil)*
Diphenhydramine HCI (compared to active ingredient in Benadryl)*
Guaifenesin (compared to active ingredient in Robitussin or Mucinex)*
Bismuth Subsalicylate (compared to active ingredient in Pepto Bismol)*
Calcium Carbonate Antacid (compared to active ingredient in Tums)*
Hydrocortisone Cream 1% for itching/rash*
Allergies to any common over the counter medication? / ¿Alergias a algún otro medicamento común de venta libre?**
I hereby consent to allow camp officials to administer common over-the-counter medication to my child. You have my permission to administer first aid and to secure medical attention for my child.
Por la presente, doy mi consentimiento para que los oficiales del campamento administren medicamentos comunes de venta libre a mi hijo/a. Usted tiene mi autorización para brindar primeros auxilios y para procurar atención médica para mi hijo/a*

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Allergies / Food Allergies**
Write none if question does not apply
Diagnosed Medical Condition OR Health / Behavioral Considerations*
Write none if question does not apply
Current Medication / Medicamento Actual*
Write none if question does not apply
Restrictions from Physical Activities*
Write none if question does not apply
Current on all Immunizations?

Yes / SiNo
Insurance Information (Optional / Opcional)

This section is optional / esta sección es opcional. If the student has medical insurance, please provide information below. Si el estudiante tiene seguro médico, por favor proporcione la información a continuación.
Does the students have health insurance?
Insurance Carrier Name
Subscriber Name (as it appears on the card)
Member ID Number
Phone Number
Please enter a valid phone number.
File Upload

Cancelof
File Upload

Cancelof

In case of emergency please list the person authorized to pick up camper other than the parent / guardian. Only names listed below will be allowed to pick up / check out campers.

En caso de emergencia, por favor indique el nombre de la persona autorizada para recoger al participante (camper) que no sea el padre, madre o tutor legal. Solo las personas incluidas en la siguiente lista tendrán permitido recoger o retirar a los participantes.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to camper / Relacion al campista
Terms and Conditions
Please read the following terms and conditions carefully before agreeing. By checking the box, you confirm your acceptance of these terms.
I have read and agree to the terms and conditions below*

I agree

Payment
Please select whether to pay in full or make a deposit

Por favor, seleccione si desea realizar el pago total o un depósito. Si su iglesia pagará con cheque, por favor hable con su líder de jóvenes o pastor.

payment*

Paid in full

$230.00 Quantity

$100 Deposit

(Non-Refundable/Non-Transferable

$100.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Should be Empty:

Camp Registration Form

Student Details

Church Information

Camper Agreement / Acuerdo de campista

Medical Information

Insurance Information (Optional / Opcional)

In case of emergency please list the person authorized to pick up camper other than the parent / guardian. Only names listed below will be allowed to pick up / check out campers.

Payment

Payment Methods