Church Camp 2017 Registration Form
Church Camp is just around the corner! To register, complete this online form and submit payment ($125) to Mt. Olive Brethren Church (2977 Pineville Road, McGaheysville, VA 22840). Registration is not considered complete until both a form and payment have been received. Once you take care of the details, all that is left to do is count down to camp! We cannot wait to see you this summer! :-)

Have questions? Contact David Miller at david@mtolivebrethren.org.

CAMPER INFORMATION
Camper's Full Name *
Your answer
Gender *
Required
Birthday *
Your answer
Grade Completed by June *
Required
Full Address *
Your answer
Parent/Guardian(s) Name(s) *
Your answer
Address (if different)
Your answer
Parent/Guardian(s) Primary Phone #(s) *
Your answer
Parent/Guardian(s) Email Address *
Your answer
Week Attending *
Required
T-Shirt Size *
Required
Name of Person Picking Up Camper *
Your answer
Relationship to Camper *
Your answer
Phone # *
Your answer
EMERGENCY AND MEDICAL INFORMATION
Adequate disclosure of health history is crucial to our ability to provide a supportive, safe and healthy environment for your camper. Please fill out this medical portion as completely as possible.
Emergency Contact Name #1 *
Your answer
Relationship to Camper *
Your answer
Phone #1 *
Your answer
Phone #2
Your answer
Emergency Contact Name #2 *
Your answer
Relationship to Camper *
Your answer
Phone #1 *
Your answer
Phone #2
Your answer
Physician's Name *
Your answer
Physician's Office # *
Your answer
Dentist's Name
Your answer
Dentist's Office #
Your answer
Insurance Company Name *
Your answer
Policy and/or Group # *
Your answer
Medical Conditions or Limitations (type N/A if none) *
Your answer
Current Medications: Prescription and Over-the-Counter (type N/A if none) *
Your answer
Allergies and Reactions: including medications, substances and foods (type N/A if none) *
Your answer
Date of Last Tetanus (best estimate if not exact) *
Your answer
PARENT/GUARDIAN CONSENTS
Medical Consent: I, the undersigned, have legal custody of the camper named previously, a minor, and have given my consent for him/her to attend this camp. I understand that there are inherent risks involved in any ministry or camp event, and I hereby release Mt. Olive Brethren Church, the Southeastern District of the Brethren Church, affiliated churches, their pastors, employees, agents and volunteers from any and all liability for any injury, loss or damage to person or property that may occur during the course of my child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church or camp staff, I agree to hold such person free and harmless of any claims, demands or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by my health insurance provider or the secondary insurance of the Mt. Olive Brethren Church. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the child named above. I also agree to bring my child home at my own expense should they become ill or if deemed necessary by the camp staff. (Checking "agree" is equivalent to signing your name.) *
Required
Photo Consent: I understand that any photographs, video and/or audio taken during the camp week may be used for future promotional and report purposes via print, video and web. I understand to exclude my child that I must submit a written request to the camp staff prior to or at check-in of my child’s camp week. (Checking "agree" is equivalent to signing your name.) *
Required
Transportation Consent: I understand that this camp week includes transportation to field trips away from the church property, and I give permission for my child to attend these field trips and leave the church in said provided transportation. I also release the church, district, affiliated churches, camp staff and drivers from any and all liability for any injury, loss or damage to person that may occur during the course of my child’s involvement in said field trips. (Checking "agree" is equivalent to signing your name.) *
Required
CODE OF CONDUCT
*Please read over the following with your camper and verify that you both have read and understand the Code of Conduct by agreeing below.
All (regardless of race, creed, color or disability) campers, staff, volunteers and visitors are expected to abide by the following rules of conduct: 1) Respect and compliance with event schedules by participating in all scheduled activities. 2) Respect of all campers, staff, volunteers and visitors. 3) Respect of all property including camp, camper, staff, volunteer and visitor property; recognizing campers and their parents are financially accountable for any damages for which they are directly responsible. 4) No immodest clothing for girls (no spaghetti strap/halter or bare-midriff tops, no undergarments exposed, only 1-piece bathing suits and only waist to middle finger tip shorts) or boys (no saggy pants, no undergarments exposed, only modest boxer-type swim trunks and shirts worn at all times). Any clothes, jewelry or other personal belongings with messages that relate to drugs, alcohol, tobacco, sex and vulgarity are NOT permitted. 5) Things to leave at home include hand held or laptop games, audio equipment, personal CD/MP3/iPod headsets and cell phones. 6) If leaving the camp in provided transportation for a camp activity, it is prohibited to do anything that would compromise the safety of anyone or be distractive to the driver. 7) Grounds for automatic dismissal include: a) possession or use of alcohol, drugs, tobacco, weapons, fireworks, lighters, explosives b) bullying, fighting, vandalism or stealing c) sexual harassment or inappropriate sexual behavior. 8) Each Camp Director has the right at any time to send anyone home without refund or reimbursement if they are found in violation of this Code of Conduct or if they do anything that would jeopardize the testimony, reputation or safety of the Southeastern District camping program or Shenandoah Meadows, Inc. (Checking "agree" is equivalent to signing your name and your camper's name.) *
Required
Date Submitted *
Your answer
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