Children’s Ministries 2014 Southwest Indiana District Children’s Camp Application Checklist All applications must be accompanied by a local church check or money order No Personal Checks 1st - 6th Grade Camp Early Registration $205 - $100 received before 5/16 & Ending balance $105. Late Registration $225 - $110 received after & Ending balance $115. Total ______________ *Cost includes snack shack card & t-shirt It is vital that we receive applications as soon as possible so that we can insure that we have enough counselors to care for the children, t-shirts for each camper, and enough supplies for games, crafts, etc. LATE REGISTRATION CAMPERS WILL NOT RECEIVE A CAMP T-SHIRT. Refunds in cases of emergency only & by discretion of the Camp & District Children’s directors. Local Church Responsibility Please make every effort to mail together all individual applications from your local church. Please review all applications to make sure they are filled out completely. Make out check or money order payable to: SWID Mail completed applications and payments to Camp Registrar: Ashlea Davis Terra Haute First Church of the Nazarene 801 Fort Harrison Road Terra Haute, IN 47804-1151 [email protected] What to bring: Bible, twin size bedding or sleeping bag, swimsuit (no bikinis), flashlight, towels, toiletries, deodorant, jacket, and any necessary medications. What NOT to bring: Electronic devices (cell phones, iPods, electronic games, radios, etc…) water guns, shaving cream, skate boards, roller blades. Keep this page for your records 2014 Southwest Indiana District Children’s Camp Application Personal Information Grade Completed Spring 2014: 1st 2nd 3rd 4th 5th 6th Gender: Boy Girl Camper’s Name: ____________________________________________ Age: ______ Preferred Name: _____________________________________________ Mailing Address: ______________________________ City: ________________ State: ______ Zip:__________ Phone Number ( ) ________________ Parent Email: ______________________________________________________________ Name of Parents/Guardians: Cell/Work Phone Numbers: ______________________________________ ( ) __________________________ _____________________________________ ( ) _________________________ SWID Children’s Camp Medical Authorization & Waiver Medical & Emergency Information Camper’s Birthday: _____/_____/_____ Height:________ Weight: ________ Insurance Company:_________________________________ 1-800 number:________________________________ Policy Number: _____________________________ Group Number:___________________ Current Medication(s): _____________________________________________________ Date of Last Tetanus Shot: / / Permission to give: Tylenol Advil Benadryl Other _____________ (Generic equivalents may be used.) List any allergies: ______________________________________________ Does your child have seizures? Yes No Date of last occurrence ________________ List any camp activity from which your child should be exempt from participating in:______________________________________________________________________________ ________________________________________________________________________________ _________________________________________________________________Family Doctor:________________ Doctor’s phone number ( )_______________ List your child’s past medical treatment if any ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________ Emergency Medical Authorization The medical information provided on this form regarding my child is correct to the best of my knowledge. I herby give permission for my child to receive over-the-counter medications marked on this application or prescription medications provided by me in original labeled container as deemed necessary by the volunteer nursing staff. I understand that the volunteer nursing staff who administers the medications according to the proper dosages shall not be held liable for any adverse reactions to the medications administered. I give my permission for my child to engage in all learning and recreational activities at the camp. I certify that my child is able to participate in those activities and that all medical conditions or allergies of my child which may limit my child’s participation in activities are listed above. IN THE EVENT I CANNOT BE REACHED IN CASE OF AN EMERGENCY, I HEREBY AUTHORIZE SWID’S DIRECTORS AND DESIGNATED PERSONNEL TO GIVE MEDICAL ASSISTANCE TO MY CHILD. I ACCEPT FULL RESPONSIBILITY FOR PAYMENT OF EXPENSES INCURRED AS A RESUTL OF ANY MEDICAL TREATMENT FOR MY CHILD. Parent/Guardian Signature: ___________________________________________________ Date:________________ 2013 Southwest Indiana District Children’s Camp Application Camper’s Name: _________________________Church:________________________ Preferences T-Shirt Size: Child Small Child Medium Child Large Adult Small Adult Medium Adult Large Adult X-Large Other Nazarene Church registered with: _____________________________ The camp staff recognizes the importance of housing with a friend. We will attempt placement with one of your choices. Roommate Choices: 1____________________ Church:______________________ 2.____________________ Church:______________________ Southwest Indiana Children’s Camp Rules & Guidelines All rules & guidelines are to be followed at all times for the best success of camp and the camper’s experience of camp. 1. No cell phones will be permitted for campers. If any campers are found with them they will be confiscated and returned to them upon departure of camp. 2. No one is allowed to leave camp grounds without permission of the directors. 3. All campers are expected to abide by the schedule for all activities. 4. Attire & Conduct should reflect modesty. Please watch your kids pack and make sure they do not bring halter tops, short shorts or short skirts (must come to finger tips), and low cut tops or pants. Girls - one piece bathing suits- NO BIKINIS. Parents: 1. Each child should be checked for head lice BEFORE coming to camp and treated if needed 3 days prior to arrival. Someone will be available to check heads before admittance to the dorms. If nits are found they will be sent home. 2. Medications must be in original containers with clear instructions. (Example Pharmacy labeling for prescription drugs or original box with medication name and dosing ranges for over the counter meds.) Loose medications without proper labeling will not be accepted or distributed by the camp nurse. I have read the above rules & guidelines and will commit to follow them. Camper’s Signature_______________________________ Date_____________ Parent’s Signature________________________________ Date_____________ Camper Application Children’s Ministries Kids Camp 2014 (Completed grades 1 - 6 Spring 2014) Shiloh Park Marion, IN June 23-27 Cost: $205 if received before May 16 $225 if received after May 16 Camp Director: Pastor Andy Wright [email protected]