Brochure

KIDS KAMP 2011 APPLICATION & LIABILITY / MEDICAL RELEASE FORM

Name:	Age:	Grade Completed:	Boy/Girl:	Camp:
			B / G	Day / Overnight
			B / G	Day / Overnight
			B / G	Day / Overnight

PARENT’S NAME: ____________________________________ PHONE: ____________________

ADDRESS:______________________________________________________________________

CHURCH: ______________________________________________________________________

EMERGENCY CONTACT: _______________________________ PHONE: ____________________

We have made every attempt to keep the cost of camp to a minimum. We would appreciate it if you would prayerfully consider helping
in any of the following areas (please check / complete):

Provide Baked Goods __ Assist w/ Crafts or Activities __ Financial Donation To Help Another Camper __ Other ________

By signing this liability release, I hereby release Christian Covenant Community, it’s officers, members, & camp staff at Kid’s Kamp from
any responsibility for injury or damages resulting from the negligence’s or other acts, however caused, resulting from my child/children’s
participation in camp. My child is voluntarily participating in these activities, with knowledge of the dangers involved & I hereby agree
to accept all risk of injury as a result of their participation, & release you the church/camp from any liability.

I (we) understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached,
I authorize the staff of Kid’s Kamp to secure the services of a licensed physician to provide the care necessary, including anesthesia, for
my child’s well-being.

INSURANCE CO: ___________________________ POLICY / GROUP NO: ___________________

NAME OF CARRIER: ________________________

SIGNED: ________________________________ DATE: ______________________________

Please list any medical allergies, medications being taken, medical problems, or other pertinent information:

__________________________________________________________________________________________

* Amount of Day Camper Fee ($100 per camper) Enclosed: __________
* Amount of Overnight Camper Fee ($115 per camper) Enclosed: __________
* Please enclose a $35.00 non-refundable deposit per child with your application. The remainder of the camp fee is due at registration.
* Please make checks payable to / mail form to: Christian Covenant Community, 712 Winding Road, Orangeville, PA 17859.
* Please make sure this entire form is completed. All children MUST have a signed release form in order to attend Kid’s Kamp.
* A suggested list of camping supplies will be provided for those who register.
* Contact information, if needed: E-mail address: jlovesm@epix.net. Phone Number: 570-864-3378. Church Website: www.cccmin.org.