Phone #: Relationship to minor:

Friend/relative to be contacted if parent/guardian is not available: Name:

Emergency Contact: Phone #:

Medications:

Allergies: Special Conditions:

Medical #: Physicians Name: Physician Phone #:

Policy Holder Name: Medical Plan:

MEDICAL

Signature of Parent/Guardian: Print Name: Date:

is a hazard to the safety and well being of others, or who appears to have rejected the reasonable guidelines of the activity.

the health and safety of the above named. I understand that CHCC at any time reserves the right to dismiss a participant who in their opinion

misfortune or damage to the above named or his/her property, with the understanding that reasonable precautions shall be taken to ensure

where deemed appropriate. I release CHCC, its elders, pastors, directors, staff and volunteers from any loss, personal injury, accident,

understanding that all reasonable attempts have been made to consult myself beforehand, except in the case of a minor illness and/or first aid

attention deemed necessary for the welfare and good health of the above named when ordered by professional medical staff; with the

Church (CHCC) MS Base Camp activities. Furthermore, I authorize CHCC, its staff or its agents to approve and obtain any and all medical

I, the parent or guardian of ___________________________, give my voluntary consent to his/her participation in Canyon Hills Community

WAIVER

A

Buck February 18-20

grades 6-8

mi

BASE CAMP is an unforgettable weekend. With tons of adrenaline-pumping mountain

activities, this camp has it all! Power-packed rallies include powerful worship and relevant

Bible teaching to challenge and inspire you. This is a weekend that you will definitely not

want to miss! Space is limited! Your registration form and a $50 deposit will hold your spot.

what what what what to to to to bring

bring bring bring ♦ Bible

♦ Journal/pen

♦ Sleeping Bag/Pillow

♦ Toiletries/Towel

♦ Warm Clothes for 3 days (including snow clothes & boots)

♦ Spending money (optional for snack bar)

♦ Snowboard/ski gear

what what what what not not not not to to to to bring

bring bring bring ♦ Cell phones, iPods or any other electronics

Speaker---- Speaker Speaker Speaker Pastor Pastor Pastor Pastor Jeff

Jeff Jeff Jeff Pastor Jeff has a quick wit and a rare talent for

turning anything into an object lesson. After

many years in youth ministry, Jeff now oversees

the Life Group Ministry and the College Ministry.

He and his wife, Cindy, have four kids and a new

granddaughter.

worship worship worship worship leader---- leader leader leader Pastor Pastor Pastor Pastor Koby

Koby Koby Koby Koby is the Associate Worship Pastor here at Canyon Hills

and led worship for us at Velocity 2010 Summer Camp.

We are thrilled to have him back leading us in worship.

Koby discovered his passion for worship in high school

and has led for many churches, schools and camps. Koby

and his wife, Halley, have a daughter named Dallas.

registration registration registration registration info:

info: info: info: Name Grade Age Male Female

Address City Zip

Phone # Email

Financial Financial Financial Financial Info:

Info: Info: Info: Camp Registration: $100 (by Jan. 16th)

$125 (after Jan. 16th)

Total Due:

Amount Enclosed:

(Minimum $50 non-refundable deposit)

OFFICE USE ONLY:

AMOUNT PAID: CASH CHECK #________

AMOUNT DUE: NOTE

Roommate Request

_________________________

We will do all possible to honor your request.

Are you in Student Life Groups? Yes No

If yes, who is you leader? _____________________

* Be sure to complete the back of this form. *

dates & info dates & info dates & info dates & info

Leave: Friday, February 18 (check-in at 4:30pm)

Return: Sunday, Feb. 20 (return to CHCC by 8pm)

Cost: $125 (after Jan. 16th), $100 (by Jan. 16th)

Where: Buck Creek near Crystal Mountain

Deadlines: $50 deposit and registration due by

Feb. 8. Limited space available!

Register by January 16th and save $25 with

registration form and non-refundable deposit.