1. automotive and vehicles
2. campers and rvs

Here are a few helpful hints and tips to make KYC a great experience for your camper!
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Please fill in each blank completely.
Applications are accepted on a first come, first served basis. It is possible for a camp to reach capacity. Please respond as soon
as possible.
Every effort will be made to accommodate rooming requests. Room assignments cannot be changed at registration.
Deposit must accompany all applications.
Please call the Youth and Discipleship Department at (859) 252-1793 or email [email protected] with questions.
Check-in: The arrival time for campers is 1:00 p.m. on Monday. Campers should not arrive prior to this time. The camp volunteers will be in a meeting until shortly before 1:00 p.m., so there will be no adult supervision.
Check-out: Check out will begin at 10:30 a.m. on the last day of camp. Campers will only be released to the person(s) indicated
on the application.
T-shirts are pre-order, pre-pay. There will be a limited amount of shirts available for sale in the camp store. When pre-ordering
a t-shirt, be very careful when indicating size. Camper will receive the size ordered.
Balance Due: In order to expedite your check-in process, it is recommended all balances due be paid 10 days prior to arrival at
camp. Please allow adequate time for processing through the mail.
The application process may take several days to complete depending on camp, your application, available space, etc. Typically, you will receive notification within 10 days. If you have not received a letter, email, or phone call by the Friday before your
child’s camp, please contact us at (859) 252-1793 or [email protected].
A $25 deposit MUST accompany application. Deposit is transferable, but not refundable.
Walk on Applications: $135. Cash, credit card or money order only.
To get the early bird rate, applications must be postmarked by May 25.
Any applications postmarked after May 25 will pay regular registration rate.
The USDA portion of the application is very important. Participation in the USDA program keeps our camp cost affordable.
Camp Director: Matthew T. Propes
Youth & Discipleship Board: Chad Keathley, Bryan Montgomery, Mike Addison, Greg Isaacs,
John Loudermilk, Mitchell Tolle, Jr., David Calvert, Chris Smith, Dale Campbell
Once application is complete, please e-mail to [email protected], or fax to (859) 252-1793, or mail to: KYC 2015
3500 Versailles Road
Lexington, KY 40510
□
2015
KYC
High School Camp June 22-26
9th - 12th graders (15-19 yrs old)
__$115 Postmarked
by May 25
__$125 Postmarked after
May 25
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□
Middle School Camp June 29-July 3
6th - 8th graders (11-14 yrs old)
__$115 Postmarked
by May 25
__$125 Postmarked after
May 25
Elementry Camp July 6-10
1st - 5th graders (6-10 yrs old)
__$115 Postmarked
by May 25
__$125 Postmarked after
May 25
**Walk on Applications: $135. Cash, credit card or money order only.**
**Any exception to age/grade guidelines must be approved by the state office. Please call or email with any questions. **
A $25 deposit MUST accompany application. Deposit is transferable, but not refundable.
Camper Information
Name
Address
City
Sta te
Male
Home Phone
Female
DOB
-
/
/
Age
-
Zip
Will be in grade
-
Cell Phone
Home Church
in August
-
Pastor
/
Pastor Signature ______________________________________________ Date
/
MANDATORY
* We will strive to roommate preferences.
Preference #1
Preference #2
Counselor Request
Medical Information
Allergies ______________________________________________
Medication/Treatment ___________________________________
Diagnosed Medical Condition _____________________________
Medication/Treatment ___________________________________
Health/Behavioral Considerations __________________________
Restrictions from physical activities ________________________
Your E -mail
Current on all immunizations ___Yes ___No
Date of last Tetanus shot ________
Food allergies ________________________________________
Doctor _____________________________________________
Phone ______________________________________________
Primary Insurance ____________________________________
Policy Number ________________ Group Number _________
As a camper of the Church of God Youth Camp, I agree to abide by the rules and policies of the camp during my stay at camp. I understand
that any deliberate breach of conduct or disregard of camp rules will necessitate disciplinary action, even to the extent of being asked to
leave the camp. Camper’s Signature ___________________________________________ MANDATORY
Payment Information
Camp t-shirts are PRE-ORDER ONLY. If you wish to purchase one, please circle size and indicate quantity.
Youth: S
M
L
$10.00 Quantity: _____
Adult: S
M
L XL $10.00 Quantity: _____
2X 3X
$12.00 Quantity: _____
Canteen and Camp Store Cards can be purchased in advance (increments of $5.00) with amount due with this application.
Camp and Canteen Cards will be available to purchase on-site also.
Canteen Cards:
____ @ $5.00 per card totaling $_________
Camp Store Cards: ____ @ $5.00 per card totaling $_________
Deposit Amount $_________
Total T-shirt Order $_________
Total included with this application: $_________
** FOR OFFICE USE ONLY
Postmarked
Incomplete
Date Returned
Deposit
Method of payment:
____ Check ____Money Order ____Credit Card
[ ] Visa [ ] Master Card [ ] Discover [ ] American Express
Credit Card Account #: _____________________________
Name on Card: ___________________________________
Expiration Date: ______/______ CVV Code: __________
Check #
Balance
Entered
USDA Completed
Parent/Guardian Must Complete
I hereby give my permission for my child to participate in any of the activities of the Church of God Youth Camp, and waive all claims to
injury or loss of property arising out of the activities against the leader of this camp, the other participants, and the Church of God Executive
Offices of Kentucky and/or International.
Parent/Guardian Initial Here ________ MANDATORY
I understand the camp insurance policy provides secondary coverage only. My insurance will provide primary coverage.
Parent/Guardian Initial Here ________ MANDATORY
I hereby consent to allow camp officials to seek and secure medical treatment for my child in the event of an emergency. I have attached a
copy (front and back) of my insurance card.
Parent/Guardian Initial Here ________ MANDATORY
As parent/guardian of the above child, I affirm that the information on this application is true and correct and that in case of illness or accident, you have my permission to administer first-aid and to secure medical attention for my child. Furthermore, I hereby authorize the release of all medical records (x-rays, test results) resulting from treatment to the Church of God Youth Camp. I also give my permission for
my child to participate in and travel to any off-site activity sponsored by the camp, if necessary.
Parent/Guardian Name
Phone #
-
-
Relationship to Child
Alternate Contact
Phone #
(In case you cannot be reached)
-
-
Relationship to Child
Parent/Guardian Signature ________________________________________ MANDATORY Date
/
/
Required Drop-Off/Pick-Up Information PLEASE PRINT CLEARLY
Who will drop off your child at camp?
Who will pick your child up from camp?
List three people authorized to visit or pick-up your child in an emergency. *ID will be required! Only visitors listed on camp application
will be permitted to visit campers.
1._________________________________ 2._________________________________ 3.__________________________________
Camper should NOT be released to or visited by the following due to court order (include copy with application):
__________________________________________________________________________________________________________
Multi-Child Discount
List other brothers and sisters attending, and the camp they will attend.
(Multi-child discount each additional child will receive a $5.00 discount off the appropriate camp fee. All campers must be from the same
immediate family.)
____________________________________________
____________________________________________
____________________________________________
____________________________________________
**USDA Form on Back**
Please complete the USDA form on the back of this page. The USDA program is a very important component of our camp. This information provided on the form is kept CONFIDENTIAL. If you have any questions, please call our office at (859) 252-1793 to discuss the
form.
If you do not complete the form, you will be asked to speak with our USDA Secretary at registration. If you are not the person dropping off
your child(ren), the USDA Secretary will be calling you to collect information.
Part 1. Children enrolled in Camp or Closed Enrolled Sites. (Use separate application for each foster child)
Names
(First, Middle Initial, Last)
Food Stamps. TANF or FDPIR case # (if
any). Skip to Part 4 if case # is listed.
Part 2. Foster Child. In certain cases, foster children are eligible for free and reduced-price meals regardless of household income. If
foster children live with you, please contact KYC @ 859-252-1793. Skip to Part 4.
Part 3. Total Household Gross Income. You must tell us how much and how often
A. Name (List everyone
in household, including
children
B. Gross income and how often it was received
Example: $100/monthly, $100/twice a month, $100/weekly
1. Earnings from work
before deductions
2. Welfare, child support, alimony
3. Soc. Sec., pensions,
retirement
4. All other income
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
$__________/__________
C. Check
if there is
no income
Part 4. Signature and Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list his or her Social Security number or mark the “I do not
have a Social Security Number” space. (See Privacy Act Statement at the bottom of this page.)
I certify that all information on this form is true and that all income is reported. I understand that this information is being given for the receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits,
and I may be prosecuted.
Sign here: X_________________________________________ Print name: __________________________________________Date: ___________
Address: ____________________________________________________________________________ Phone number: _______________________
Last Four (4) Digits of Social Security Number: __ __ __ __ OR ______ (check) “I do not have a Social Security Number”
Part 5. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:
____ Hispanic or Latino
____ Not Hispanic or Latino
Mark one or more racial identities:
____ Asian
____ American Indian or Alaska Native
____ White
____ Native Hawaiian or other Pacific Islander
____ Black or African American
Don’t fill out this part. Official use only.
Annual Income Conversion: Weekly X 52, Every 2 weeks X 26, Twice a Month X 24, Monthly X 12
Total income: _______________ Per: (Circle one) Week, Every 2 Weeks, Twice a Month, Month, Year
Household size: _____________
Categorical Eligibility: _______________ Date Withdrawn: ____________ Eligibility: (Circle one) Free, Reduced, Denied
Reason: ________________________________________________________________________________________________
Temporary: (Circle one) Free, Reduced Time Period: _________________ (expires after _____ days)
Determining Official’s Signature: ____________________________________________________________ Date: __________
Confirming Official’s Signature: _____________________________________________________________ Date: __________
Follow-up Official’s Signature: ______________________________________________________________ Date: __________
Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we
cannot approve your child for free or reduced price meals. You must include the Social Security number of the adult household member who signs the application. The Social Security
number is not required when you apply on behalf of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on
Indian Reservations (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a Social
Security number. We will use your information to determine if your child is eligible for free or reduced-price meals, and for administration and enforcement of the Program.
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political
beliefs, marital status, familial or parental status, sexual orientation, or if all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the
Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the
form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington,
D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected] Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).