Chaperone Name *

First Name

Last Name

Gender *

Male

Female

Have you completed Safe Gatherings Training? *

Safe Gatherings training is required for ALL Regional Youth Volunteers. If you have not already completed this training, please contact Nisha7@aol.com to begin the process. While adults are allowed to attend events without the training, they are not able to serve in the full capacity of leadership during the weekend. The process can take several weeks so please contact Nisha ASAP if you need to complete Safe Gatherings.

Yes

No

Phone 2 *

(###)

###

####

Camp Covenant *

• I will come to camp with the intentions of supporting the children in their covenant listed below: - Expecting to grow in my faith and in relationship with others, becoming a special part of the camp community. In order to do this, I covenant to follow all the rules and guidelines set by the Christian Church in Alabama Northwest Florida and any others set for this event. With this, I commit myself to the following: To be on time, attend and be attentive for all camp/conference activities and participate in them fully • Have fun and make sure everyone else has a great time • To respect each other regardless of age and to respect others’ feelings and thoughts • I will not go from adult to adult until I get the answer I want • Be myself and open to making new friends • Be inclusive at all times • Cooperate with the counselors, keynoter, director and other staff members at all times • Be respectful of God’s beauty in this special place and only leave footprints behind • To take all that I learn about God and share it with my friends, family and church.

Yes, I agree to support the youth in this covenant

Do you have any health problems? *

Yes

No

Are you currently under the care of a physician or psychologist? *

Yes

No

Do you expect to have any difficulty with normal event activities? *

Yes

No

Do you have any food or other allergies? *

Yes

No

Do you take any prescription medication? *

Yes

No

Photo Permission *

I hereby give permission for my photo to be included in candid shots or group photos which may appear in flyers or on the Region's website.

Yes

No

Emergency Contact Number *

(###)

###

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Payment Options *

$130 per youth/adult

I will be paying the full amount online today

I will be mailing my full payment by check or money order to the Regional Office

I am making partial payment online today (my church will be sending in the remainder on my behalf)

I am not making payment today, my church will send in my full payment on my behalf.