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