WA State Youth Camp Application

Sponsored by Church of God of Prophecy

Name_______________________________Male [  ] Female [  ] Birthdate________Age_____________ 

Address__________________________________City___________State_______Zip_______________

Home Phone #______________ Emergency Phone #_________________E-Mail__________________

Camp Applying:               [   ] Teen Winter Retreat Ages 13-19 [   ] Sr Camp Ages 13-19

[   ] Jr. Camp Ages 8-12[   ] YAK Camp Ages 18-30[   ] YAK Retreat Ages 18-30

Tuition: Junior Camp $145 ~ Sr. Camp $145 ~ Teen Winter Retreat $75

~ YAK Camp & Retreat $75 (Deposit required  for all camps and retreats~ $25.00)

I would like to donate an extra $10  $20  $50 or $________towards recreational equipment.

(Please designate on your check the amount of your donation.)

Please mail application and deposit to: Bob and Donella Gaines 18604 Silverleaf Pl Arlington, WA 98223

bndgaines@isomedia.com360-435-9567

Make checks payable to: WA State Camps

Medical Information

Is he/she on a special diet? Yes [   ] No [   ] If yes please specify ____________________________________________

Are there any activities that the camper should not participate? Yes [   ] No [   ] If yes please specify _____________________________________________________________________________________________

Family Physician________________________ Phone (_____)____________________________________________

Does your family have health insurance? Yes [  ] No [  ] If yes please list your insurance carrier

Name and address of insurance _____________________________________________________________________

Insurance Group/ID Number: _______________________________________________________________________

Please list any medical condition the camp needs to be aware of and/or comments_______________________________

Any allergic reactions to: Bee sting [  ] Penicillin [  ]  Food [   ] _____________________ Other____________________

All medications must be administered by the camp nurse for campers 18 yrs and younger. The nurse will collect the medications at the time of registration.

I understand that if any accident or sickness should occur which requires emergency treatment, the campers private insurance will be considered primary insurance.  Any insurance coverage provided under The Church of God of Prophecy camp insurance is secondary coverage.  The Church of God of Prophecy Youth Camp, Directors and Staff will not be held liable for any accident, sickness or expense relating to the same.  In case of emergency, I understand that every effort will be made to contact the child's parent or guardian.  If the parent or guardian cannot be reached, permission is hereby given to the camp staff and/or physician to secure proper treatment for and/or hospitalization, and to administer injection, anesthesia, surgery and/or any other emergency treatment deemed necessary for the minor child named above.

Do you give permission for the summer camper, if under age 18 to participate in baptism? Yes [   ] No [   ]

I understand that in signing this application that my child is agreeing to abide by all the rules, policies and discipline of this Camp as set forth by the Director and Staff.  I also understand and agree to the medical coverage/treatment as set forth above.

Dated: __________________________ Signature _____________________________________________________

                                                                                                                            [  ] Parent     [  ] Guardian

Printed Name of Parent or Guardian ____________________________________

Camper Signature ___________________________________________

office~ Date received_____________ Deposit received ______________Amount Due at Registration ______________