Teen Fall Retreat Registration Form

Camper's Name

First NameLast Name

Birth Date

MonthDayYear

Grade in School

Gender

Address

Street Address

Mailing Address

CityState / Province

Postal / Zip Code

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

Name and Address of Church

Does your child take any prescription or OTC medications on a regular basis? If yes, please list

Are there any OTC medications you DO NOT wish your child to receive? If yes, please list.

Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Conditions:

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

Informed Consent and Acknowledgement

What to Bring: Bible(KJV), notebook & pen, sleeping bag/blanket (TWIN), 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 Friday night chapel service. Other ideas: camera, ball glove, fishing equipment, and spending money (suggest $15-40) for canteen & bookstore.

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.

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.

I haveI read and understand the standards and important information listed above. I agree to abide by the standards of Living Water Farms, and I give permission to use my (child's) photographs in future publication/promotions.

Camper Signature

Parent/Guardian Information

Name

First NameLast Name

Emergency Contact's Name (if different than above)

First NameLast Name

Phone Number

Format: (000) 000-0000.

Relationship

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.

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

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

Payment Methods

Debit or Credit Card

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

Teen Fall Retreat Registration

Child Information

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

Payment Methods

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