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APPLICATION FORM
 ( For Each Youth And Adult Campers
And Staff )
NOTICE: One
Form Per Person Please! You May Make More Copies Of
This Form for
More Campers If Necessary. Use Your Mouse To
Copy The Highlighted Form From The
Top To The Bottom Of Form, And
Paste It In Your Word Processor.
NAME:
__________________________________________________________________________
ADDRESS:
_______________________________________________________________________
CITY:
________________________________ STATE: ________________ ZIP CODE: ___________
PHONE: ( _____ ) _____ - ______
BUSINESS: ( ______ ) ______ - _______
Age ____ Sex _____
Birth Date: ____ / ____ / ____ S.S.N.
# ______ - ______ - ______
DEAF / HARD-OF-HEARING / HEARING
(Circle One)
Grade as of Fall 2008: ____________
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CHURCH AFFIANT: |
____________________________________________________________________________
____________________________________________________________________________
(Name of your congregation in city and state)
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QUESTION FOR
PARENTS/GUARDIANS
OF YOUTH CAMPERS
(AGE 9-18): |
IF YOUR YOUTH CAMPER WANTS
TO BE BAPTIZED, MAY HE OR SHE DO SO? ____________________
Parents/Guardians name(s):________________________________________________________
CAMPER’S AGREEMENT:
(Every
Youth and Adult camper and Staff must sign)
“I agree to abide by all of the
rules and policies of Deaf Christian Camp/Quartz Mountain Christian
Camp.”
SIGNED_______________________________________________ DATE: _____________________
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MEDICAL INFORMATION
(For each
Youth and Adult camper and Staff) |
Health Insurance Company:
________________________________ID#_____________________
Group #
______________________ Card
# (if any) ____________________________________
Payer ID #
_____________ Card Calling # (
) _______________________________________
Expiration Date: __________ Policy Holder Name: ______________________________________
(The Insurance provided by the
Camp is a supplementary policy. The Camp Insurance will be used
ONLY
if your do not have INS policy for your kid(s) or yourself).
EMERGENCY CONTACT:
Name:___________________________________________ Phone #: _______________
HEALTH INFORMATION:
Allergies:________________ Health Condition? ______________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Name of any Medications:
___________________________________________________________
(All
medications
must be labeled with name of camper and given to the
Camp Nurse on the day of Registration).
***Parents: “My child is updated with
all routine Immunizations” YES/NO If no, explain:
________________________________________________________________________________
________________________________________________________________________________
Last Tetanus Shot Date:
______________ Does your child have any Social/Emotional problem
that we need to be Aware of ?
________________________________________________________________________________
________________________________________________________________________________
Will your child be limited by
any camping activity (hiking, swimming, etc.) ?________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
RELEASE
OF LIABILITY AGREEMENT:
“I/We agree
that the camp is released from any liability in connection with the
camper named in this application, except as is covered by camper
insurance carried by the camp. I also give my consent for emergency
medical treatment.”
SIGNATURE: ______________________________________ DATE:
__________________________
(Every Adult camper and
Parents/Guardians of Youth camper and Staff must sign)
If You Have A Problem with This Application Form,
Please contact Chris Nipper at: chrisnipper@deafchristiancamp.org
THE CAMP PAYMENT:
CHECK YOUR PAYMENT:
(All checks
and money order payable to DEAF CHRISTIAN CAMP)
____1) Enclosed is $145.00 per
adult camper for entire camp fee if
sent on or before June
7, 2008.
____2) Enclosed is $135.00 per
youth camper for entire camp fee if
sent on or before June
7, 2008.
____3) Scholarship
(for youth
only) or Family Rate. Either one is applicable only on or before the
deadline,
June 7, 2008. (Check with ____________ first before mailing this
form).
PAYMENT ENCLOSED:
$____________ BALANCE TO PAY ON June 7, 2008:
$______________
MAIL YOUR PAYMENT TO:
Director, Chris Nipper
2822 County Meadows Lane
Maryville, TN 37803-3064
For any questions, send
email at:
chrisnipper@deafchristiancamp.org
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