Oklahoma Deaf Christian Camp

APPLICATION FORM

DEAF CHRISTIAN CAMP

JULY 11-16, 2010

( For Each Youth And Adult Campers And Staff )

You may Download the Application Form to Your File.
Please click on each link below...

1. Application Form To Be Copy, Paste and Print

2. Copy all web page (See NOTICE below)

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 2010: ____________

CHURCH AFFIANT:

_______________________________________________________________

_______________________________________________________________
(Name of your congregation in city and state)

QUESTION FOR
PARENTS/GUARDIANS OF YOUTH CAMPERS
(AGE 9-18):

IF YOUR YOUTH CAMPER WANTS TO BE BAPTIZED, MAY HE OR SHE DO SO? YES OR NO: _________________________________________________
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: _____________________

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)

THE CAMP PAYMENT:

CHECK YOUR PAYMENT: (All checks and money order payable to DEAF CHRISTIAN CAMP)

____1) Enclosed is $155.00 per adult camper for entire camp fee if sent on or before June 15, 2010.

____2) Enclosed is $145.00 per youth camper for entire camp fee if sent on or before June 15, 2010.

____3) Enclosed is $165.00 per adult camper for entire camp fee if sent after June 15, 2010.

____4) Enclosed is $155.00 per youth camper for entire camp fee if sent after June 15, 2010.

____5) Enclosed is the non-refundable and non-transferable registration fee of $75.00 per adult or youth camper if sent on or before June 15, 2010, (After the deadline, the adult camper fee of $165.00 or youth camper fee of $155.00 have to be paid, in this case go to #3 and #4). The balance of adult camper is $80.00 or youth camper is $70.00 to be paid on the first day of camp.

____6) Scholarship (for youth only) or Family Rate. Either one is applicable only on or before the deadline, June 15, 2010. (Check the director first before mailing this form).

PAYMENT ENCLOSED:

$____________ BALANCE TO PAY ON June 15, 2010: $______________

MAIL YOUR PAYMENT TO:

Beth Cunningham
DCC Secretary
5815 County Road 1500
Lubbock, TX 79407