Sr. High
Jr. High
Pastor’s Kid
Staff’s Kid
YOUTH CAMP 2015
JULY 27-31
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Name:_________________________________________________________________________________________
Last
First
MI
[ ] Female
[ ] Male
Email Address: _______________________________________________________________
Age ________ Birth date mm/dd/yyyy :______________________________________________________
Attended NYI Camp Last Year? [
]Y [
]N
Is your parent a sponsor or staff worker at camp?
Grade Next School Year: _____ T-shirt Size: Small
Medium
Large
XLarge
2XLarge
[
]Y
[
]N
3XLarge
Preferred Roommate to stay with: _____________________________________________________________________
Home Church (list city and state of church): ______________________________________________________________
Home Phone: (
)___________________________ Parent’s Alternate Phone: (
)__________________________
Parent or Guardian Name:____________________________________________________________________________
Home Address: ___________________________________________________________________________________
Street and number
City
State
Zip
In emergency, (if unable to reach parents) notify: _________________________________________________________
Phone:(
)_____________________ Address:_________________________________________________________
Street
City
State
Zip
Signature of Student
_____________________________________________ Date___/____/_____
Signature of Parent/Gaurdian _____________________________________________ Date_____/____/_____
IN CASE OF MEDICAL EMERGENCY—I consent to the necessary medical and/or dental treatment, including the decision for hospitalization, and necessary, surgery, herby authorizing the Prairie Lakes NYI or President Jourdan Suos or other assigned leadership or administrator of the Prairie Lakes NYI to secure the necessary medical or dental treatment for said minor and to receive any necessary assistance. I, ___________________________________________, of ___________________________, ________________________________ (Name of parent or guardian) (City) (County) _______am the [ ] father, [ ] mother, [ ] legal guardian (check one) of_______________________________________ (State) (Name of minor child) a minor of ____________________________________, ________________________, ___________ of whom I have full (City) (County) (State) custody and control, who will be attending Teen Camp at Crystal Springs Camp Ground, City of Medina, County Stutsman, State of North Dakota. $50 Deposit due with registration (checks only please). Early Bird Price is $180. Price after June 29th $225. Paintball is an additional fee of $10.00. Must be pre-‐registered by July 13th to attend. NO WALK-‐INS ALLOWED. Registration begins at 5:00 PM. Questions call Kelley Lovelace at 605-‐645-‐1682. Please Mail these forms & Check to: Rhonda Lovelace 8348 112th Ave. SE, Oakes, ND 58474 MAKE CHECKS PAYABLE TO: PRAIRIE LAKES NYI. Make sure you read and sign all forms. THE FOLLOWING INFORMATION IS GIVEN RELATIVE TO SAID CHILD’S MEDICAL HISTORY: Allergies:___________________________________________________________________________________________
__________________________________________________________________________________________________ Medications being taken: ____________________________________________________________________________ Date of Last Tetanus Shot:_________________________________. Physical Impairments:________________________ Other pertinent facts to which physicians should be alerted:_________________________________________________ Insurance Company:________________________________________________________________________________ Insurance Policy Number:______________________________________ Dated this _________________ day of (month) 20_____ at _______________________________________________________________________________________ (City) (County) (State) Signature of Parent or Guardian: ________________________________________________________________
RELEASE OF ALL CLAIMS Release made this ______ day of ___________, 20____ by ________________________________________, (Day) (Month) (Year) (Name of Parent or Guardian) of ____________________________________________, ______________________________, __________ (City) (County) (State) as [ ] parent [ ]legal guardian (check one) of ___________________________________________________ (Name of Minor child)
I hereby release and discharge Prairie Lakes District Nazarene Youth International and, its agents, executors, administrator, or assigned employee, of any claim against Prairie Lakes District Nazarene Youth International, its successors or assigned employee, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by or arising out of, the above described Prairie Lakes District Teen Camp to be held at the Crystal Springs Camp Ground and the surrounding area. I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full know-‐ledge of its significance. I have executed this release as parent or guardian of the above child as stated above. Signature of parent or guardian:______________________________________________________________ SPECIAL PAINTBALL WAIVER In consideration of Prairie Lakes NYI furnishing services and/or equipment to enable me to participate in paintball games, I _________________________________________________ agree as follows: • I fully understand and acknowledge that; (a) risks and dangers exist in my use of Paintball equipment and my participation in Paintball activities; (b) my participation in such activities and/or use of such equipment may result in my injury or illness including but not limited to bodily injury, disease strains, fractures, partial and/or total paralysis, eye injury, blindness, heat stroke, heart attack, death or other ailments that could cause serious disability; (c) these risks and dangers may be caused by the negligence of the owners, employees, officers or agents of Prairie Lakes NYI; the negligence of the participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. These risks and dangers may arise from foreseeable or unforeseeable causes; and (d) by my participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, employees of Prairie Lakes NYI, or by any other person. • I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify Prairie Lakes District NYI and it’s owners, agents, officers and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of Paintball equipment or my participation in Paintball activities. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers or employees of Prairie Lakes NYI. This waiver is good through 12/31/2015. Registrants Signature: _______________________________________________________________________________ Signature of Parent or Guardian: ______________________________________________________________________ CAMP 2015
In order to ensure that Camp is a fun, safe, and enjoyable for everyone we have a few rules and
guidelines for you. It is our hope to have fun, while providing a safe environment to make new friends
and hang out with old ones. We want you to have a great camp experience with an opportunity to
spend time with Jesus and learn from him.
We ask that the student camper and their Parent/Guardian understand that by signing the camp
registration form you agree to follow all rules and guidelines for PLD summer teen camp 2015. We
are looking forward to seeing you at camp. Thank you!
Camp Essentials (ALL the buildings are air conditioned.)
Clothing – YOU WILL GET DIRTY AT CAMP!!!!! -‐ Modest Sportswear during the day. -‐ Girls/ Guys – modest swim suit. (No Speedos or bikinis, Please!) -‐ Old Clothes for paint ball and other messy activities. Toiletries – PLEASE USE THESE!!!!! - Towels - Soap & Shampoo - Toothpaste & Toothbrush Bedding – Don’t forget a pillow! - Sleeping Bag & Pillow - Blankets & Sheets for Twin Size bed. Other items – You may want these things! - Bible, Pen or Pencil - Money for Snacks, Pop, etc. - Money for a meal on the way home - You can bring your cell phone but you are responsible. Things Not To Bring – - Matches, lighters, fireworks, anything with fire attached or needs a flame to work! - Alcohol, drugs, cigarettes & chewing tobacco - No Firearms, Knives, Bombs, Missiles, RPG’s or Weapons of Mass Destruction. FYI- Cell Phones are permitted but they are your responsibility.
The Crystal Springs Camp and Prairie Lakes NYI are not liable for loss or damage.
* We ask that no girls be in the guys dormitory and no guys be in the girls dormitory at all.
* We expect everyone to participate and have fun
* We expect all registrants to follow the schedule and curfew set by the PLD Camp Staff.
CAMP 2015
FAQ’s
Where is Camp? Crystal Springs Bible Camp, Medina, ND. July 27-31.
Why should I go to Camp? It is a fun place to experience Jesus and make new friends.
What will we be doing this year? Some of the old favorites are back - paintball, group
games, mud pit and water sports.
If I want to be an adult staff person, what must I do? Fill out an application, abuse registry
check and a pastoral recommendation. To be staff, you must be at least 21 years of age.
Send the adult registration to: Kelley Lovelace, 8348 112th Ave. SE, Oakes, ND 58474.
Please let us know as soon as possible if you are interested.
If I am a staff person, does my son or daughter get a reduced rate? Yes. We are
allowing parents serving as staff a rate of $140 for every student in your immediate family—
sons, daughters, and step kids if preregistered.
Who is speaking? Ed Belzer grew up in Miller, SD. He attended MNU and seminary and
has been a youth pastor for 25 years. Ed has a great love for teens! He is currently a youth
pastor in Colorado and is married and has a daughter.
What ages is camp for? Camp is for students who are heading into 6th grade to students
just graduated as of 2015.
Do you have to attend a Nazarene Church to go to camp? No. Any student may come.
Why do I have to pre-register? This will save you money! Pre-registration helps us in
planning meals, activities and housing.
I am a parent. Why should I trust you with my student? It is our goal to provide a safe
environment for your teenager to experience Jesus Christ. We know that the camp
experience will provide an opportunity for your teen to build relationships that will benefit them
as they grow.
If you have more questions, email me at [email protected].