Camp Dates & Pricing: May 13-15: Camp Caleb (Age 50+) - $65 June 9-14: Camp Friendship (Special Needs) - $185 June 23-28: Elementary Week - $250 June 30-July 5: Middle School Week - $250 July 7-12: High School Week - $250 1 Camper/Parent Agreement2 Camper Information3 Medical Information4 Parent Information5 Payment Information I, the camper, am aware of the camp policies and guidelines. I understand that this is a church related camp and that certain standards of conduct will be required of the camper. If accepted, I agree to abide by the camp rules. I agree to demonstrate respect for the camp staff at all times. I understand that if I fail to keep my agreement, I may be asked to leave camp. I give permission to use pictures in which I may appear in camp brochures, flyers or other promotional literature both electronic or published and used by the camp. Camper Signature*Use your mouse to draw your signature.Church Name*Pastor's Name*As parent/guardian, I have read the Camp Policies and Guidelines and have reviewed them with my child. I accept them and expect my child to abide by them. I will be responsible for any and all property damaged by my child when he/she is at camp. I also understand that CYC provides secondary insurance coverage and will not be liable for any expenses beyond that which is covered by insurance. In case of a simple accident or illness, the camp director may make necessary arrangements. If the accident or illness is serious, I request the camp director to take all necessary steps to insure my child’s health. I give permission to use pictures of my child (as a camper) which may appear in camp brochures, flyers, or other promotional literature—both electronic or published and used by the camp.Parent/Guardian Signature*Use your mouse to draw your signature.Date* Date Format: MM slash DD slash YYYY Name* First Last Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Birthdate* Date Format: MM slash DD slash YYYY Age During Camp*Grade by Camp*Gender*MaleFemaleScholarship*YesNo It is the camper’s or Parent/Guardian’s responsibility to insure the camper through their own group or individual policy. Should a camper become sick or injured at CYC, the camper’s insurance through his/her parent/guardian (or personal) primary policy must file a claim on that coverage first. Should a camper have no insurance coverage or if the insurance carrier denies the claim, then a claim will be filed on the limited accident policy carried on all campers by CYC (secondary). The parent/guardian and/or the camper are financially responsible for medical treatment costs not covered by CYC’s limited accident insurance. If you have questions, call 910-892-4161. Medical Insurance Carrier*Group #*Policy #*Is the camper in good health?*YesNoIs camper able to walk?*YesNoIs camper allergic to any medications?*YesNoPlease list medications camper is allergic to.*Other allergies:*Does camper take any medications?*YesNoWhat medications and how often?*Notify the camp director if this camper is exposed to any communicable disease during the 3 weeks prior to camp attendance.Are all shots current/up-to-date?*YesNoDate of last shots* Date Format: MM slash DD slash YYYY List any chronic or recurring illness and any special emergency care normally given:Specify any normal camp activities that camper may not participate in: Parent/Guardian Information*NameHome PhoneCell PhoneEmail Please list at least one parent/guardian for us to contact if needed. Emergency Contact Name*Cell Phone*Home PhoneRelationship to Camper*Who will be picking your child up on Friday?*PLEASE NOTIFY THE CAMP DIRECTOR IF THIS CHANGES. Please choose the week of camp attending:*Camp Caleb (Age 50+)Elementary WeekMiddle School WeekHigh School WeekSee top of page for dates.Total $0.00 Payment Options*Pay OnlineBill to My ChurchChurch Name to Bill*Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name