Kids’ & Youth

Camp 2011

Tri-State Free Methodist Camp

1027 Anderson BoulevardEast Liverpool, Ohio 43920

www.tri-statefamilycamp.com

•Monday, June 20 - Friday, June 24•Monday, June 27 - Friday, July 1

2011

Guest speakers: * Please take note: There will be a skit and karaoke night during camp. If you have some-thing that would be appropriate for these per-formances, you can bring it with you.

The 10 Commandments of Camp• You MUST take showers.

(Due to certain activities, you will most likely get sweaty and dirty.)

• Obey directions of camp leaders.• Wear shoes at ALL times.

• All medications must be given to the camp nurse for distribution.

• Wristbands MUST be worn at all times or you will be sent home.

• You MUST stay with your coach when you are off camp property.

• Boys and girls are NOT permitted in each others dorms.

• Only those campers assigned to your room are permitted to be in there, un-less your coach has two rooms and

needs to use one for devotions.• There will be NO profanity used at camp.• There will be NO fighting while at camp.

• I agree to abide by all of the camp rules & participate in the total camp program:

________________________________(Camper signature)

• The camp director has the right to con-tact parents to pick up unruly children.

* This camp is for all of God’s children regard-less of gender, race, color or national origin.

• Pastor Barb Barnhart, Youth CampMonday, June 20 - Friday, June 24* Entering grades 6 through 8 in the fall

• Pastor Chuck Thomas, Kids’ CampMonday, June 27 - Friday, July 1* Entering grades 3 through 5 in the fall

• Cost: $100 for first child; $85 for each additional child from the same immediate familyMake checks payable to the Pittsburgh Conference Kids’ Camp & mail to: Randy Phillips1347 1st AvenueConway, PA 15027

• Registration forms postmarked by June 11 will receive a FREE t-shirt. Registration begins at 3:00 p.m. on the first day of camp.

• What should I bring to camp?Bible, towels, washcloth, toiletries, pj’s, swimsuit, sleeping bag (bedding), pillow, clothes for rainy days, flashlight, fan, bug repellent, money for store & a good atti-tude * Special note to parents & guardians: Money should be kept in name tag holders for safe keeping.

• What should I leave at home?CD player, radio, iPod, mp3 player, knives and

other sharp objects, shaving cream, squirt gun, laser pointer, matches, lighter, tobacco, alcohol,

drugs & cell phone. * If it is necessary for you to have a cell phone, it must be turned in to the camp director.

Kids’ & Youth Camp Registration FormPersonal information:

Name _________________________________

Gender ____ Male ____ Female

Address _______________________________

City ______________________ State _______

Zip code __________ Church ____________

Phone number _________________________

SSN# _________________________________

Date of birth __________________________

Age ______ Grade entering in fall ______

I will be attending ____ Kids’ Camp (grades 3-5) (June 27 - July 1) ____ Youth Camp (grades 6-8) (June 20 - June 24)Please list one (1) roommate preference:

_______________________________________

Circle shirt size: Child S, M, L Adult S, M, L, XL, XXL

Health information:Pre-existing or current medical condition ____ Y ____ N Please explain: ______________ _________________________________________________________________________________________________________________________________________________________________________________.

Allergies ____ Y ____ N Please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Name & dosage of any medications that must be taken _____________________________________________________________________________________________________________________________________________________________________________________.

Date of last Tetanus shot _______________

Contact lenses ____ Y ____ N

Swimming or activity restrictions ____ Y____ N Please explain: _____________________________________________________________________________________________________________________________________________________________________________.

Height ____________ Weight _________lbs.

Do we have permission to treat your child with over-the-counter medications ____ Y ____ N Circle if permitted: Tylenol, Ibuprofen, Tums, Pepto-Bismol, Other ______________________

* Please send or attach any additional information you think necessary in order for us to give your child proper medical care if they receive injuries or con-tract an illness during their time with us at camp.

Do you have health insurance ____ Y ____ N

If you have insurance, your carrier will be billed for medical charges in case of ill-ness or injury while your child is at camp.

Name of insurance company __________________________________________________

Policy number __________________________

Group number _________________________

Name on policy _________________________

Family doctor __________________________

Phone number _________________________

Emergency information:

• Parent/Guardian _______________________________________________________________

Home phone # __________________________

Work phone # __________________________

Cell phone # ____________________________

• Alternate contact ______________________________________________________________

Home phone # __________________________

Work phone # __________________________

Cell phone # ____________________________

[Please use the back of this form or securely attach another page to it for additional information, if necessary.]

Medical & Liability Release Statement

• I understand that if medical intervention is needed, every attempt will be made to immediately contact the persons listed on the registration form. If I can not be reached in an emergency during the activity dates shown on the registration form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, secure medical treatment and/or order an injection, anesthesia or surgery for my child as deemed necessary.

• I understand that my insurance coverage for my child will be used as primary coverage in the event that medical intervention is needed. Coverage by the Pittsburgh Conference Children’s Ministries accident policy will be used as a backup for what my family’s insurance does not cover.

• I understand all reasonable safety precautions will be taken at all times by the Pittsburgh Conference Children’s Ministries and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold the Pittsburgh Conference Children’s Ministries, its leaders, employees and/or volunteer staff liable for damages, losses, diseases or injuries incurred by the subject of the registration form.

____________________________________(Parent/Guardian Signature)

Date:__________________________________

For:

__________________________________(Camper’s name)