Kids’ & Youth

Camp 2012

Tri-State Free Methodist Camp

1027 Anderson BoulevardEast Liverpool, Ohio 43920

www.tri-statefamilycamp.com

•Monday, June 25 - Friday, June 29•Monday, June 18 - Friday, June 22

2012

Guest speakers: * Please take note: There will be a skit and karaoke night during camp. If you have some-thing that would be appropriate for these per-formances, you can bring it with you.

The 10 Commandments of Camp• You MUST take showers.

• Obey directions of camp leaders.• Wear shoes at ALL times.

• All medications must be given to the camp nurse for distribution.

• Wristbands & name tags MUST be worn at ALL times.

• You MUST stay with your coach when you are off camp property.

• Boys and girls are NOT permitted in each others dorms.

• Only those campers assigned to your room are permitted to be in there,

unless otherwise approved by your coach or the director

• There will be NO profanity used at camp.• There will be NO fighting while at camp.

“I have read and agree to the above rules. I understand that if there is a problem the director has the authority to contact my parent/guardian.”

________________________________Camper signature

________________________________Parent/guardian signature

• Stefanie Mitchell, Kids’ CampMonday, June 25 - Friday, June 29* Entering grades 3 through 5 in the fall• Pastor Tim Miller, Youth CampMonday, June 18 - Friday, June 22* Entering grades 6 through 8 in the fall• Cost: $100 for first child; $85 for each additional child from the same immediate familyMake checks payable to the Pittsburgh Conference Kids’ Camp & mail to: Randy Phillips, 1347 1st Avenue,Conway, PA 15027• Registration forms postmarked by June 8 will receive a FREE t-shirt. Registration begins at 3:00 p.m. on the first day of camp.• What should I bring to camp?Bible, towels, washcloth, toiletries, pj’s, swimsuit, sunscreen, tennis shoes, flip-flops, sleeping bag (bedding), pillow, clothes for rainy days, flashlight, fan, bug repellent, money for store & a good attitude * Special note to parents & guard-ians: Money should be kept in name tag holders for safe keeping.• What should I leave at home?CD player, radio, iPod, mp3 player, snacks or drinks requiring refrigeration that exceed one per day, knives and other sharp objects, shaving cream, squirt gun, laser pointer, matches, lighter, tobacco, alcohol, drugs & cell phone. * If it is necessary for you to have a cell phone, it must be turned in to the camp director.

• What is the dress code?FOR BOYS: all pants must be worn around the waist;

shirts are required at all times except for swimming. FOR GIRLS: no short shorts; no strapless tops or tanks

that expose bra straps or midriffs, one-piece bathing suits are recommended. If a two-piece suit is worn that does not meet in the middle a t-shirt is required to wear over it.

This camp is for all of God’s children regard-less of gender, race, color or national origin.

Kids’ & Youth Camp Registration FormPersonal information:

Name _________________________________

Gender ____ Male ____ Female

Address _______________________________

City ______________________ State _______

Zip code __________ Church ____________

Phone number _________________________

SSN# _________________________________

Date of birth __________________________

Age ______ Grade entering in fall ______

I will be attending ____ Kids’ Camp (grades 3-5) (June 25 - June 29) ____ Youth Camp (grades 6-8) (June 18 - June 22)Please list one (1) roommate preference:

_______________________________________

Circle shirt size: Child S, M, L Adult S, M, L, XL, XXL

Health information:Pre-existing or current medical condition ____ Y ____ N Please explain: ______________ _________________________________________________________________________________________________________________________________________________________________________________.

Allergies or special dietary needs ____ Y ____ N Please explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Name & dosage of any medications that must be taken _____________________________________________________________________________________________________________________________________________________________________________________.

Date of last Tetanus shot _______________

Contact lenses ____ Y ____ N

Swimming or activity restrictions ____ Y____ N Please explain: _____________________________________________________________________________________________________________________________________________________________________________.

Height ____________ Weight _________lbs.

Do we have permission to treat your child with over-the-counter medications ____ Y ____ N Circle if permitted: Tylenol, Ibuprofen, Tums, Pepto-Bismol, Other ______________________

* Please send or attach any additional information you think necessary in order for us to give your child proper medical care if they receive injuries or con-tract an illness during their time with us at camp.

Do you have health insurance ____ Y ____ N

If you have insurance, your carrier will be billed for medical charges in case of ill-ness or injury while your child is at camp.

Name of insurance company __________________________________________________

Policy number __________________________

Group number _________________________

Name on policy _________________________

Family doctor __________________________

Phone number _________________________

Emergency information:

• Parent/Guardian _______________________________________________________________

Home phone # __________________________

Work phone # __________________________

Cell phone # ____________________________

• Alternate contact ______________________________________________________________

Home phone # __________________________

Work phone # __________________________

Cell phone # ____________________________

[Please use the back of this form or securely attach another page to it for additional information, if necessary.]

Medical & Liability Release Statement

• I understand that if medical intervention is needed, every attempt will be made to immediately contact the persons listed on the registration form. If I can not be reached in an emergency during the activity dates shown on the registration form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, secure medical treatment and/or order an injection, anesthesia or surgery for my child as deemed necessary.

• I understand that my insurance coverage for my child will be used as primary coverage in the event that medical intervention is needed. Coverage by the Pittsburgh Conference Children’s Ministries accident policy will be used as a backup for what my family’s insurance does not cover.

• I understand all reasonable safety precautions will be taken at all times by the Pittsburgh Conference Children’s Ministries and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold the Pittsburgh Conference Children’s Ministries, its leaders, employees and/or volunteer staff liable for damages, losses, diseases or injuries incurred by the subject of the registration form.

____________________________________(Parent/Guardian Signature)

Date:__________________________________

For:

__________________________________(Camper’s name)