WE ARE EXCITED TO SEE YOU IN 2023! 1Camper/Parent Agreement2Camper Information3Medical Information4Parent Information5Payment Information6 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. Campers Name* First Last Camp Week*Please choose what week the camper will be attending. This is based on what grade the camper will be in when they start school in the Fall of 2023.Please choose what week you will be attending.Elementary Week #1 (Grades K-2nd) June 15-18, 2023Elementary Week #2 (Grades 3rd-5th) June 18-23, 2023Middle School Week (Grades 6-8) June 25-30, 2023High School Week (Grades 9-12) July 2-7, 2023Gender* Male Female Grade by Camp* Camper T-Shirt Size*This year a t-shirt is included in the registration fee. Please let us know what size your camper wears. Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult 2X-LargeAdult 3X-LargeAdult 4X-LargeCanteen Card*This year a canteen card is included in your registration fee. Elementary Week #1 (K-2nd) will receive a $10.00 canteen card and all other weeks will receive a $20.00 canteen card. If your child has any money left after their camp week, please indicate what you would like us to do with the remaining balance. I would like to donate the remaining balance to future CYC projects. I would like to be refunded the balance, only if my camper has $7.00 or more left on his/her canteen card. I would like to be refunded the full remaining balance that is left on my campers canteen card. Birthdate* MM slash DD slash YYYY Age During Camp*Room Request*Please list any room request in this area. Church Name* What city is your church located in?* 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 Name* First Last Parent/Guardian Signature*Use your mouse to draw your signature.Date* MM slash DD slash YYYY 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 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?* Yes No Is camper able to walk?* Yes No Does the camper have any known allergies and/or allergic to any medications?* Yes No Please list all known medication(s) allergies and any other known allergies.*Does camper take any medications?* Yes No What medications and how often?*Are all shots current/up-to-date?* Yes No List any chronic or recurring illness and any special emergency care normally given:Specify any normal camp activities that camper may not participate in: Consent* I have read and agree the visitor policy.VISITORS: For the safety of our campers, staff and volunteers - no visitors will be allowed on CYC campus during camp weeks. 1. We will operate within a “camp bubble” this camp season, this strictly limits visitors on camp property. 2. Visitors will not be allowed on camp property at any time during the summer. This includes parents, friends, pastors, or anyone who is not approved. Essential visitors, such as food delivery, plumbers, electricians, etc. will be allowed on camp property and maintain social distancing standards. 3. If for any reason a visitor needs to come on campus, he/she must be approved by the Camp Director before being allowed on camp property. Consent* I agree to the photo/video release agreement below.I grant permission to Crusader Youth Camp & the PFWB Orginization, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at Crusader Youth Camp for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner. I hereby release Crusader Youth Camp and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.” Parent/Guardian Information*Please list at least one parent/guardian for us to contact if needed. NameHome PhoneCell PhoneEmail Emergency Contact Name*In the event of an emergency, the parent above will be notified first. Please list an additional emergency contact person, incase we are unable to reach the parent listed above. Phone Number*Relationship to Camper* Who will be picking your child up on Friday?* PLEASE NOTIFY THE CAMP DIRECTOR IF THIS CHANGES. Camper Signature*Use your mouse to draw your signature.Parent/Guardian Signature*Use your mouse to draw your signature. Please choose the week of camp attending:*Please choose the week of camp attending:Elementary Week #1 (K-2nd) // June 15-18, 2023Elementary Week #2 (3rd-5th) // June 18-23, 2023Middle School Week // June 25-30, 2023High School Week // July 2-7, 2023See top of page for dates.Payment Options*Pay OnlinePay at Check-inBill to My ChurchPlease know that if you choose "Bill to My Church", we will contact the pastor/youth pastor of that church to verify that they will pay for you/your child to attend. If your church declines payment, then you are responsible for the full registration fee. To pay at check-in, use the code CHECKIN; To bill a church, use the code CHURCH Church Name to Bill* Online Processing Fees* Price: $0.00 Total $0.00 Credit CardCard Details Cardholder Name