Spring Teen Retreat Registration Form

Camper's Name

First NameLast Name

Birth Date*

MonthDayYear

Grade in School

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Roommate Choice (optional, one choice only, no guarantees):

Name and City of Church

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

YesNo

List any physical problems that would limit activity or other ohysical problems (bed wetting, sleep walking...) :

Informed Consent and Acknowledgement

What to Bring: Bible(KJV), notebook & pen, sleeping bag/blanket, pillow, washcloth, towel, soap, toothbrush, toothpaste, comb, & any other toiletries. Clothes- jacket, casual clothes and tennis shoes for recreation (these clothes could get dirty), and dress clothes for chapel services. Other ideas: camera, ball glove, fishing equipment, and spending money (suggest $25-40) for canteen, bookstore & special activities.

Leave at Home: Leave all electronic devices (radios, MP3 players, tablets, computers, cell phones, etc), magazines/books, fireworks, & playing cards. Campers who bring tobacco products, alcoholic beverages, or illegal drugs will be sent home at their expense.

Insurance: Campers provide their own primary insurance. The camp provides secondary insurance only.

Friends of LWF are always welcome to visit

Visitors are encouraged to attend our evening services. If possible, contact the camp at 319-592-3770 to let us know you are coming.

Dress Code:

God’s Word teaches the importance of modesty and distinction between male and female. As a Christian Camp we want to reflect Scriptural principles and ask our family campers, junior and teen campers, and staff to abide by the following rules while staying at Living Water Farms.
*All Campers All clothing must cover from neck to knee. Sleeveless or tight fitting clothing is not permitted. Living Water Farms reserves the right to request a change in any clothing or behavior deemed inappropriate.
*Girls/Ladies Modest, loose-fitting and knee-length recreational attire is appropriate for activities; no pants, gauchos, or capris. Spaghetti-strapped or low-cut shirts are not allowed. Knee-length skirts or dresses must be worn to the Friday evening service. Skirt slits may not be higher than the knee.
*Boys/Men No shorts, sleeveless, or see-thru mesh shirts. Pants and collared shirts must be worn to the Friday evening chapel service.

Yes

Camper Signature*

Parent/Guardian Information

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Insurance Company and Policy #

Medical Release and Authorization

IN CASE OF EMERGENCY, I understand every effort will be made to contact parents or guardians. In the event that I cannot be reached, I hereby give permission to the physician selected by Living Water Farms to hospitalize and secure the proper medical treatment for, and other injection or anesthetic or surgery for my child as named on this form. I realize my insurance will be billed for any medical treatment as the primary coverage for my child.

Yes, I understand

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date*

Date

Parent or Guardian Signature*

Please verify that you are human*

Email Address to receive registration confirmation

example@example.com

Online Payment- use PayPal button, debit/credit available there. Please use coupon code PAYLATER to bring a check with you to camp.

Complete Payment

$35.00

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

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

Spring Teen Retreat Registration

Child Information