Session Two

Information

A Camper Always Comes Prepared

Instructions

Complete the “Session Two Application” application below
Print, sign, and bring the “Immunization Record” (below) with you to the first day of camp.
Print, sign, and bring the “Annual Physical” (below) with you to the first day of camp.
Review the ‘Session Two Pack List‘ (below) for your camp session.

Session Two Application

"*" indicates required fields

Step 1 of 7 - Camper Info

Please Read

All prospective campers and/or their parents/guardians must complete this application in its entirety and provide all signatures that are requested.

A payment of $125 (plus online processing fees) will be submitted at the end of this application. If you need financial assistance or do not wish to pay online, please contact Four.Corners.Youth.Encampment@gmail.com before starting the application.

Camper Information

Name*

First Last

This person will be referred to as "the camper" for the remainder of this form.

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Sex*

Male

Female

Age*

Please enter a number from 13 to 19.

Grade*

Please enter a number from 9 to 12.

What grade is the camper going into?

Birthdate*

Unisex Shirt Size*

Parent / Guardian One Information

A second parent / guardian may be added after the first.

Name*

First Last

Work Phone*

Cell Phone*

Would you like to add a second parent?

Yes

Parent / Guardian Two Information

Name

First Last

Work Phone

Cell Phone

Approved Guardians

The camper MAY leave the camp premises in the company of:*

The camper MAY NOT leave the camp premises in the company of:*

Emergency Contact Information

Name*

First Last

Home Phone*

Work Phone

Employer Name

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Additional Information

Has the camper been baptized

Yes

Where was the camper baptized?

May the camper be baptized at camp?

If approval is given, you will be called from camp prior to the baptism of your child

Yes

Camper Agreement

Camp Policies

Every person is required to follow the camp schedule unless excused by the session director.
The “raiding” of cabins and/or hazing of any kind is absolutely prohibited.
The harm of other persons and/or the destruction of property are grounds for immediate dismissal from camp.
Each camper must bathe regularly and be properly groomed and attired. Modest dress and undergarments are required for males and females. The staff, and session director retain the authority to ask anyone on the premises to change their attire if it is deemed inappropriate for camp. When packing clothing, remember to bring clothing appropriate for warm and cold temperatures.
Alcohol, illicit drugs, tobacco and any harmful substances are not permitted.
Guns, hunting knives, hatchets, matches, or fireworks are not permitted. Possession of these items is grounds for immediate dismissal from camp.
Abusive and/or profane language are not permitted. The respectful and honest treatment of all persons is expected.
All prescription and non-prescription medication, vitamins, and/or supplements of any kind MUST be given to the camp nurse upon registration.
The nurse must be notified of any medication routine.
All persons must bring their own sunscreen. The camp will not provide any and no sharing of sun screen will be allowed.
No camper is allowed to leave the premises without the permission of the camp director and without the accompaniment of those specifically noted in this form. Parents are asked to check in with the camp director before taking their child off the premises.
Cell phones are permitted for camera use only. Any personal media use is permitted only at the discretion of the session director.
Do not bring food or beverages to camp. All food, snacks , and beverages will be supplied by the camp. There is NO food allowed in the cabins.
Visitors must check in with the camp director and abide by all policies outlined in this section. All vehicles should be parked in the designated area.
The session director may expel any person (camper, staff member, or visitor) from camp premises if there is conduct is detrimental to the camp.

Name*

Full name of the camper

First Last

Consent to Administer Medical Care*

By checking this box, I consent to administer medical care

I authorize Four Corners Encampment to administer and /or seek appropriate medical care on my behalf. I know that in the case of emergency (specifically, in the event I become incapacitated), effort will be made to contact my emergency contacts (using the emergency numbers listed in the application). If, however, no one can be reached, I hereby give permission to the physician, nurse practitioner, paramedic, first responder, or other trained healthcare professional selected by the camp director and/or its medical staff to hospitalize and secure proper transport and treatment (including surgery and invasive medical procedures) for myself. I also give permission for the camp medical staff to administer non-prescription health aid.

Health Insurance Company*

Health Insurance Policy Number*

Camper Consent*

By checking this box, I agree to abide by all camp policies provided above to the best of my ability. I will obey the camp director, cabin leaders, teachers, and other staff.

Photo Release Consent

By checking this box, I hereby consent to Four Corners Youth Encampment using any photos/videos of me during this camp session for use on their website or any other camp approved advertising.

Parental Agreement

Name*

Full name of the parent / guardian completing this form

First Last

Photo Release Consent

By checking this box, I hereby consent to Four Corners Youth Encampment using any photos/videos of my child during this camp session for use on their website or any other camp approved advertising.

Bug Spray & Sunscreen Consent

By checking this box, I hereby consent to Four Corners Youth Encampment providing bug spray and/or sunscreen during this camp session.

Consent*

I agree to these Terms and Conditions

Terms and Conditions

I understand the terms of this registration and it has my approval. It is agreed that Four Corners Encampment, Inc. assumes no responsibility for the camper’s personal property and is released from liability in connection with medical ministrations except as covered by camper insurance.

I give permission for my child to be disciplined in an appropriate manner and by the appropriate camp staff if his/her conduct is in violation of camp policies. I understand that any disciplinary measures used will be non-physical and will be constructive or education in nature, and may include measures such as diversion, separation from problem situations, talking with the child about the situation, and similar measures. I understand that I will be notified by the camp director if my child’s behavior is harmful to himself/herself or to others and is detrimental to the conducting of camp.

I give permission for my child to go on trips away from camp premises, whether on foot or by vehicle. I give permission for my child to participate in all camp activities with the following exceptions:

Please note that Four Corners Encampment offers opportunities for swimming and river play, sports activities and other active games, hiking, campfires, fun with water balloons, arts and crafts, Bible classes, worship assemblies, etc. Please indicate to us any restrictions you wish to place on your child’s activity at camp. Policies and safety procedures regarding camp activities are posted at www.cortezchurchofchrist.org.

Payment

Camp Fee: $125
Online Processing: $3.93

Camp Two Session*

Price:

Credit Card

Card Details

Cardholder Name

This field is for validation purposes and should be left unchanged.

Session Two

Information

A Camper Always Comes Prepared

Instructions

Session Two Application

Please Read

Camper Information

Parent / Guardian One Information

Parent / Guardian Two Information

Approved Guardians

Emergency Contact Information

Additional Information

Camper Agreement

Camp Policies

Parental Agreement

Payment

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