Parent/Guardian Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Format: (000) 000-0000.

How many youth are you registering?

If you need to register more than for children, please contact the church office.

First Youth

First NameLast Name

First Youth's Date of Birth

Date

First Youth's Age

First Youth's Gender

First Youth's Health Card Number

Does your youth have any Medical or Allergy concerns you need to share?

First Youth's Medical History

All medications (including Epi-pens) must be submitted to our church office in it's original prescribed bottle with your child’s name on it.

Second Youth

First NameLast Name

Second Youth's Date of Birth

Date

Second Youth's Age

Second Youth's Gender

Second Youth's Health Card Number

Does your youth have any Medical or Allergy concerns you need to share?

Second Youth's Medical History

All medications (including Epi-pens) must be submitted to our church office in it's original prescribed bottle with your child’s name on it.

Third Youth

First NameLast Name

Third Youth's Date of Birth

Date

Third Youth's Age

Third Youth's Gender

Third Youth's Health Card Number

Does your youth have any Medical or Allergy concerns you need to share?

Third Youth's Medical History

All medications (including Epi-pens) must be submitted to our church office in it's original prescribed bottle with your child’s name on it.

Fourth Youth

First NameLast Name

Fourth Youth's Date of Birth

Date

Fourth Youth's Age

Fourth Youth's Gender

Fourth Youth's Health Card Number

Does your youth have any Medical or Allergy concerns you need to share?

Fourth Youth's Medical History

All medications (including Epi-pens) must be submitted to our church office in it's original prescribed bottle with your child’s name on it.

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Waiver (required)

I, the undersigned, hereby declare and affirm that: I am the parent/legal guardian of
the youth listed above, who is under my care and responsibility. I give permission for my child to attend and travel to Ministikwin Youth Bible Camp and participate in all of the youth camp activities associated with The Word Church of Lloydminster. I understand that participation in camp activities may include, but is not limited to, physical activities such as swimming, kayaking, sports, games, hiking, and other outdoor activities. I acknowledge that there is a risk of injury, illness, or other harm that may arise from these activities. In consideration of my child's participation, I assume all risks, whether known or unknown, of my child's participation in the youth Bible camp

I release and discharge The Word Church of Lloydminster, its staff, volunteers, and agents from any and all liability, claims, demands, and causes of action that may arise from my child's participation in the camp, including any harm, injury, or loss that may occur.

Authorization for Medical Treatment

In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or medical facility selected by my child’s advisor and/or group leader to secure proper treatment for my child as named above.

I understand that the camp shall not be responsible, and shall be reimbursed, for any medical expenses incurred by them over this authorization.

Photographic Release

By clicking accept, I grant The Word Church and its representatives to take photographs and/or video recordings of my child, during his/her participation in camp activities.

I understand that these photographs and/or video recordings may be used in various promotional materials, including but not limited to brochures, newsletters, websites, social media, and other promotional materials created or distributed by The Word Church.

I hereby release and discharge The Word Church, its representatives, and any person acting under its permission or authority, from any claims or liabilities whatsoever arising out of or in connection with the use of the photographs and/or video recordings.

This waiver and release shall be governed by and construed in accordance with the laws of the Province of Saskatchewan, Canada.

Questions or Comments

Parent / Guardian's Full Name

First NameLast Name

Signature

Date

How many youth are you paying for?

Total amount owing for registration is $175

Total amount owing for registration is $350

Total amount owing for registration is $525

Total amount owing for registration is $700

Payment Method:

Please submit cash payment to the office as soon as possible.

Etransfer Funds to give@thewordchurch.ca.

In memo, include "registration fee", and youth's name.

Credit Card Payment

Youth Camp Registration Fee

$175 for each youth

$175.00 CAD Quantity
Item subtotal:

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Deeper 2026

Youth Camp Registration

Parental Information

Registration Information

Emergency Information

Parental Consent

Waiver (required)

Authorization for Medical Treatment

Payment

Credit Card Payment