Agape Youth Camp Eugene 2018 Registration
The Agape Youth Camp is a camp for kids ages 7-17 who live in Oregon and either currently have, or have previously had, a parent that is incarcerated. Agape Youth operates two camps every summer, one in Eugene for families living in Eugene and surrounding cities, and one in Salem for families living in Salem or surrounding cities. If you would like to register for the Salem camp, return to our website www.agapeyouthoregon.com and select the Salem camper registration.

The dates for the Agape Youth Eugene camp are August 23rd-26th, 2018 at Camp Harlow.

If you have any questions please email us at agapeyouthoregon@gmail.com.

Camper Information
My camper is... *
(a returning camper or a new camper)
First Name *
Your answer
Last Name *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Zip *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Gender *
Grade in Sept. 2018 *
What school will this camper attend in the fall of 2018?
If this is different than the school they attended in the spring, please include both schools.
Your answer
T Shirt Size *
Sweatshirt Size *
How did you hear about Agape Youth Camp? *
example: Family First at OSP, friend Faith Gilchrist, Angel Tree, Radio.....etc.
Your answer
Parent/Guardian Information
Parent/Guardian 1 First Name *
Your answer
Parent/Guardian 1 Last Name *
Your answer
Parent/Guardian 1 Legal Relationship *
Required
Parent/Guardian 1 Home Phone
555-555-5555
Your answer
Parent/Guardian 1 Cell Phone *
555-555-5555
Your answer
Parent/Guardian 1 Email *
(Email is our primary way of communicating with you about updates and upcoming events)
Your answer
Parent/Guardian 2 First Name
Your answer
Parent/Guardian 2 Last Name
Your answer
Parent/Guardian 2 Legal Relationship
Parent/Guardian 2 Home Phone
555-555-5555
Your answer
Parent/Guardian 2 Cell Phone
555-555-5555
Your answer
Parent/Guardian 2 Email
Your answer
Who is incarceraterd in relation to the camper *
If it is an adopted parent or step parent please check other and explain
Required
If you selected "other" please explain the camper's relationship with their parent in prison.
Your answer
What is the name of the camper's incarcerated parent? *
We are in partnership with Prison Fellowship, and this information is required for the financial support of your camper attending camp.
Your answer
Where is the camper's parent incarcerated? *
Example: OSP (We are in partnership with Prison Fellowship, and this information is required for the financial support of your camper attending camp)
Your answer
Current contact with incarcerated parent *
Please share any additional info you'd like for us to know about your family's situation.
Your answer
Do you have any prayer requests for your family or your child's experience at camp?
Your answer
Does your camper have any siblings who will also be attending camp? If so, please provide their full names. *
Your answer
Camper Needs
Agape Youth Camp is happy to provide most of the campers needs for the time they are at camp. Some campers would prefer to bring their own sleeping bag and pillow to camp, so we would like the families to tell us what each camper will need. Please check the boxes telling us what supplies you would like to bring yourself.
Which of the following supplies will your camper be bringing to camp with them?
The supplies that are not listed below are ones that all campers will receive, regardless if they have it or not (t-shirts, sweatshirt, cinch sack, hair brush, tooth brush, toothpaste, Bible, journal, pen, and pillow case)
Emergency Contact Information
This person will be contacted if Parent or Guardian is unavailable.
Emergency Contact First Name *
Your answer
Emergency Contact Last Name *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Cell Phone *
555-555-5555
Your answer
Emergency Contact Work Phone
555-555-5555
Your answer
Release of Minors at end of Agape Youth Camp Eugene
All campers are released at the end of camp to their legal parent/guardian or one of the individuals listed below. NO EXCEPTIONS! Please remember a photo ID must be presented.
One approved pick up person, other than legal guardian.
Name and Phone
Your answer
Legal parent/custodial issues
Are there any current or pending legal parent/custodial issues? If yes, we will send a form to obtain more information.
Health and Medical Information
Name and Phone of Camper's Physician *
Your answer
Name and Phone of Camper's Dentist *
Your answer
Insurance Company *
Your answer
What is the date of your Camper's last tetanus shot? *
Your answer
Please list any current medical conditions or concerns, or any recent injury.
Your answer
Does your camper have Asthma? *
Known Allergies
Please list details and treatment for any known allergies marked above
Your answer
Does your camper need a special diet?
If yes, please explain.
Your answer
Special Considerations, Limitations, Needs or Behavioral Issues
To help set your camper up for success, please share any additional information that would be pertinent for our staff to know. Please list below.
Your answer
Instructions for medications while at Agape Youth Camp
1. All medication must be turned in to the nurse at registration. DO NOT pack in your camper's luggage.
2. Medication must be in original containers with the campers name and instructions.
3. Sample medications will be accepted with a doctor's note authorizing the medication with dosage and instructions.
4. All medication is kept in the Nurse's Station and administered there.
5. Campers who need emergency inhalers or epi-pens must carry them at all times. You may choose to leave these with the nurse. If not, you must leave a backup supply at the Nurses' Station.
6. Over the counter medications are not accepted. Please see the list below of over-the-counter medications on hand.
Medications and Dosage
Please include names of medications, times to be given and reason for each medication. If medication changes before camp starts please let us know.
Your answer
Over the counter Medications
Please mark any medication that you DO NOT want your child to have.
2018 Agape Youth Camp Parental Release
Please check yes or no for each of the following releases.
I, the parent or legal guardian of the above camper, hereby give permission to Agape Youth and Camp Harlow to administer medications as listed above. I understand that it is my responsibility to provide prescription medication in original pharmacy containers or as labeled physician samples.
Permission for medication *
Required
I understand that if my camper requires medical attention in addition to the descried above, that Agape Youth and Camp Harlow will attempt to contact me first. If I am unavailable, I authorize Agape Youth to contact my camper's physician. If neither I nor my child's physician is available, I authorize Agape Youth and Camp Harlow to order X-Rays, routine tests, and treatments; to release any records necessary for insurance purposes; and to provide or arrange records necessary for insurance purposes; and to provide or arrange transportation for my camper to a nearby clinic or hospital. I will hold harmless, Agape Youth and Camp Harlow and all associated staff from any claim of liability arising from attending camp.
Permission to help in emergency *
Required
I, the parent or legal guardian of the above camper, hereby give permission for my camper to travel to and participate in offsite Agape Youth events. These events will be listed in the schedule given to parents at check in.
Permission to travel *
Required
For promotional or marketing purposes, Agape Youth reserves the right to use any audio, video, and/or photography of campers participating in Agape Youth facilitated events.
Permission for use of picture *
Required
I, the parent or legal guardian of the above camper, hereby give permission for my camper to participate in Agape Youth and Camp Harlow activities such as: Swimming Pool, Zip Line, Bumper Boats, Archery, Go Carts, Outdoor games, Inflatables, Rock Wall, Flying Squirrel, Low Ropes Course, Put Put Golf, Big Swing and Program Activities.
Permission for activities *
Required
Agape Youth 2018 Requirements
I agree to the following *
By checking the box, you acknowledge our policies
Required
Signature of Parent or Guardian *
Please include your full name and date. Note: By Checking the above permissions and signing you acknowledge that you are the parent/legal guardian of this camper, and that you have read and agreed with each item.
Your answer
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