SNEMN Office Use Only: _____ Entered in to the Computer _____ Payment PAID In Full _____ Medical Papers/Insurance Info _____ Waiver Complete _____ Pick Up Person Known _____ Reg. Complete _____ Confirmation Sent _____ Camper Has Arrived ! 2015 SNEMN SUMMER CAMPS! ! TEEN CAMP APPLICATION ! SR. HIGH: JULY 6-10, 2015 (GOING INTO GRADE 9-12TH) ! JR. HIGH: JULY 13-17, 2015 (GOING INTO GRADE 6-9TH) ! Camper First Name: ________________________ Camper Last Name ___________________________ Address: _______________________________________ City/State/Zip:_________________________________ Grade Completed: _________ Date of Birth: _______/_______/_______ Age: ____ Male: ____ Female: ____ Email Address to Confirm Camp: _________________________________________ Parent/Guardian’s Name:_______________________________ Phone:___________________ Emergency Contact (if different than parent): ______________________________ Phone:___________________ Has camper been convicted of any crimes or currently on probation? _____ Yes or _____ No If yes, explain:____________________________________________________________________________________ ! Name(s) of person/church to pick up camper at Rumney Bible Conference Camp: Bryan Francis _________________________________________ ! _____________________________________________ Desired Roommate (Limit 2 Names):_____________________________________________________________ Church Name/City/State:________________________________________________________________________ Please check with desired roommate to confirm they are listing you & the same week. Roommate MUST also pre-register. ! ! REGISTRATIONS MUST BE SENT THROUGH YOUR CHURCH CAMP COORDINATOR Malden / MA CHURCH City/State:__________________________________________________________ Freedom Hill Community Church Church Name: _______________________________________________________________ Bryan Francis 781-321-2121 Camp Coordinator’s Name: ______________________ Coordinator’s Phone: _______________________ Youth Pastor or Senior Pastor’s Signature: X ___________________________________________________ 2015 SNEMN SUMMER CAMPS! TEEN CAMP REGISTRATION COSTS Check all that apply: DEADLINE IS 5/10 ! Early Bird Registration - per person - $255 - Postmarked by 5/4 ! Each Additional Child from same household - $230 - Each 5/4 OnlyUntil available until 5/10 Name of 2nd Child: _________________________________________________________________ Name of 3rd Child: _________________________________________________________________ ! Normal Registration - per person - $275 - This applies to any and all registrations 10 Family Postmarked after 5/4. Discounts Not (Family Discount notAvailable availableAfter after5/4. 5/10) ! Late Registration - $305 - Postmarked after 6/1 Applications received after deadline date will only be accepted as accommodations permit. ! ! CAMP AMENITIES: (included with Registration) Swimming, Canoe/Paddle Boats, Tubing, Hiking, Late Night Bonfires, Game Room, Snack Shop & Team Competitions. **For An Additional Cost: _____ Paint Ball (Teen Camp Only) $25 per player (Equipment, 1 hour of play & 500 rounds) _____ Camp T-Shirt $10 Each Please indicate what size T-Shirt: _________ Adult Size (S/M/L/XL/2XL) Other _____ T-Shirts & Sizes are only guaranteed if your Registration is received by May 4th! 10th ! Registration Cost Policy: Registration Costs are Non-Refundable, but are (same gender) transferrable. A $15 fee will be applied to returned checks No walk-ins will be accepted. ! Make checks payable to your church and give to your church’s Camp Coordinator with your child’s registration form. 2015 SNEMN SUMMER CAMPS! ! ! AUTHORIZATION RELEASE/DISCIPLINARY CLAUSE I ___________________________ (parent/guardian), understand that participation in camp activities with the Southern New England Ministry Network Camp brings with it a certain amount of risk. I understand what those activities are as outlined in the camp registration and give my child ________________________ permission to participate in all activities. Should there be any activity for which I wish for my child to abstain from, I will notify the Southern New England Ministry Network Camp in writing at the time of registration. In consideration of the risks involved, I understand that the Southern New England Ministry Network Camp and White Mountain Retreat Center have taken the necessary precautions to ensure the safety and well being of my child. I hereby release and waive any and all claims against the Southern New England Ministry Network Camp, White Mountain Retreat Center, and its staffs arising from his/her participation in the Southern New England Ministry Network Camp. I also release and waive all personal financial responsibility for any injury or loss sustained during the activities and hold both the Southern New England Ministry Network and Rumney Bible Conference harmless for such injury or loss arising directly or indirectly from said activities. ! The health history included in this application is correct as far as I know and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician. IN CASE OF EMERGENCY, I hereby give permission to the physician to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. I hereby give my consent, in the event that all reasonable attempts to contact me have been unsuccessful, for the administration of any treatment deemed necessary by the appropriate licensed physician, nurse, dentist or emergency personnel. ! I also hereby understand that if my child refuses to adhere to the camp policies listed herein, I may be called to bring him/her home immediately. I also hereby give permission to the camp counselor and/or other member of the camp staff to inspect the contents of any or all of my child’s personal belongings, and to withhold and/or dispose of any improper or illegal contents. I also hereby give permission for my child to be transported off grounds to participate in the recreation activities of the camp program. ! I also give permission for the Camp Nurse to administer over the counter medication to my child as deemed necessary according to dosing guidelines and attend to any other necessary healthcare means. I authorize SNEMN Camp Ministry to use my child’s likeness in photographs or video in any and all of its publications and in any and all media pertaining to camp. I will make no monetary or other claims against SNEMN Camp Ministry for the use of such photos and or videos. This record is confidential and viewed by appropriate staff only. ! ! _____________________________ Parent/Guardian Signature ! ! _____________________________ Please Print Name _____________________ Date Student Consent: I will abide by all camp rules. I understand violation of these guidelines may result in my immediate dismissal from camp at parent/guardian’s expense. ! _____________________________ _____________________________ Camper Signature Please Print Name !STATEMENT OF PHYSICAL EXAMINATION AND HEALTH HISTORY! All campers must have a physical within TWO years of the start of camp. Copies from last year are not available. THIS original form is required. ! Send this medical form to your doctor NOW! DO NOT WAIT! Be sure this form is filled out COMPLETELY and send it back to your church’s camp coordinator by the registration deadline date. This form is REQUIRED to be sent in with the camp application and is REQUIRED for your child to stay at camp. Do not leave any lines blank. If not applicable, please write N/A. This helps our medical staff care for your child. ! Applicant’s Name: ________________________________ Date of Last Physical:______________ Physician’s Signature: X_________________________________ Physician’s Name & Address___________________________________________ Phone:__________________ Insurance Provider: _________________________________________________ Phone:__________________ Carrier’s Name: ____________________________________________Group #:_________________________ Special medical or dietary instructions___________________________________________________________ ! History of: ___Seizures ___Heart Trouble ___Diabetes ___Sore Throat ___Kidney ___Bowel Problems ___Bleeding ___Fainting ___Menstrual Problems ___Sleepwalking ___Bedwetting ___Nosebleeds ___Headaches ___Allergies ___Hay Fever ___Asthma ___Bee Stings ___ Plants ___ Other (explain)_______________________________________________________________________ Medication or Food Allergies___________________________________________________________________ Explanation for checked items:_________________________________________________________________ Physical Handicaps, Disorders, Diseases _________________________________________________________ Mobility limitations/Activity restrictions___________________________________________________________ Parents Notes to Counselor: (likes, dislikes, fears, injuries, traumas)___________________________________ ! IMMUNIZATION RECORD - MANDATORY DPT - dates ______________ DT - dates ______________ OPV - dates ______________ MMR - dates ______________ Td - dates ______________ HepB - dates ______________ TB - dates ______________ ! MEDICATIONS: List all medications to be administered at Camp________________________________________________ ______________________________________________________________________________________ All medications must be in original container and clearly labeled: patient’s name, physician’s name, name of medication, prescription number, date prescribed, instructions. DO NOT SEND OVER-THE-COUNTER Medications (i.e.Tylenol or Advil) as the nurse has these on hand. Exception: Claritin with Doctor’s note and instructions. ! The following over the counter medications will be available in brand name or generic name and age appropriate dosing and form, i.e. liquid or tablets and will be given according to label dosing guidelines: Acetominophen (Tylenol), Ibuprophen (Advil), Benadryl, Sudafed, Mylanta, Tums, Immodium, Auri-Dri, Neosporin, Calamine Lotion, Hydrocortisone Cream, Robitussin, Cough Drops, and any other over the counter medication deemed necessary. If your child takes another OTC medication on a regular basis, please send that with a doctor’s note for administration at camp.” Important SNEMN Camp Information! Questions about Camp? Call the Youth Dept. at: 508-248-3711, Ext. 729 You Must Register through your church’s Camp Coordinator. No Walk-ins! CAMP LOCATION: White Mountains Retreat Center, 31 Gilford Avenue, Rumney, NH 03266 / 603-786-9504 Instructions and General Information! General Camp Rules 1. 1. Give your full payment with the provided registration, !health record and a copy of camper’s immunization record to your church’s camp coordinator.! 2. Make checks payable to your church.! 3. Camp fees include lodging, meals and recreational activities.! 4. We encourage campers to register early to assure ! them a place at camp. All registrations are filled on a first-come, firstserve basis.! 5. Arrival Time is 1:00PM.! 6. Departure Time is 12:00PM (Please be prompt).! 7. Facilities: All campers will stay in supervised dorms/cabins. Dorms/cabins are not air conditioned.! 8. Mail: Daily “Mail Call” is a highlight of camp. You may !send mail with camper’s name to: White Mts. Retreat Center, PO Box 599, Rumney, NH 03266. Please write “SNEMN Camp” in lower left corner of envelope. Letters !must be mailed one week prior to the start of !camp in order for the camper to receive it.! 9. Telephone: Camper’s are requested not to call home unless there is an emergency. Permission to use the camp phone must be approved by the Camp Director. Incoming calls are also discouraged unless there is an emergency. In case of an emergency, you may leave a !message by calling the camp at 603-786-9504.! Please Note: Any prescription drugs brought to camp must be in their original bottle. No over-the-counter drugs allowed! These are provided at camp. Campers are under the authority of the camp staff during their stay at camp.! 2. Campers are not permitted to leave the camp unless a written request by a parent/legal guardian is presented at registration.! 3. Campers must stay in their rooms after “Lights Out.” Any camper caught outside after this time without a ! proper reason will be sent home.! 4. Campers are expected to conduct themselves in an appropriate manner at all times and to attend all scheduled activities.! 5. Use of tobacco, drugs, alcohol or other illegal contents is strictly forbidden.! 6. No profanity, disrespectful or crude conversation is to be used.! 7. Turn in any iPods, electronic games, cell phones, etc. that you have brought to camp. They will be returned at Check Out time.! 8. Keep your room clean. Room checks will be done during morning Chapel services.! 9. Respect other camper’s belongings.! 10. Do not damage or deface any camp property. If something is broken, report it immediately. Unnecessary damage will be charge to the person(s) responsible. If the guilty person(s) cannot be found, the cost of the repair will be shared by each camper in the room.! 11. Check Out at the end of the week at the registration table. Each camper will be free to go home AFTER their room has been cleaned and approved by the Camp Director. Campers should understand that violations of camp rules may result in disciplinary action, the contact of their parent/legal guardian with the possibility of being sent home and forfeiting their camp fee.! ! Mark Your Belongings! Not responsible for lost or stolen items. Please leave all valuables at home. What To Bring: What NOT To Bring: • Modest Attire - T-shirts and shorts are acceptable. No tank tops or midriffs permitted. Shorts must be “finger tip” length from the knee. If you are not appropriately dressed, you will be sent back to your room to change. • One-Piece Swimsuits Only • Spending Money • Sleeping Bag or sheets, blankets and pillow • Camera • Towels • Baseball Glove • Flashlight • Rain Gear • Bible & Notebook • Sneakers • Personal Care Items: Soap, shampoo, toothpaste, etc. • Bug Spray • • • • • • • • • iPods Radios Electronic Games Firearms / Fireworks Tobacco Cell Phones Illegal Drugs Knives or Weapons Over-the-Counter Drugs • • • • • • • • • Tank Tops Sleeveless Shirts Tube Tops Strapless Dresses Pornography Mini Skirts Short Shorts Sorts Expensive Jewelry
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