SUMMER CAMP APPLICATION
Camp Echeconnee
Church of God of Prophecy
Georgia
CAMPER INFORMATION
Camper Name: ______Address: ______
City: ______State:______Zip: ______Phone:______
Date of Birth: ______Age by Camp: ______Sex (Male or Female): ______
E-Mail Address: ______
PARENT/GUARDIAN INFORMATION
Fathers Name:______Mothers Name: ______
Fathers Phone at Work: ______Mothers Phone at Work:______
Fathers Address (if different): ______Mothers Address (if different): ______
______
CAMP INFORMATION
Camp Applying For:
Senior (15 -19 yrs)______Junior (12 - 14 yrs) ______Freshman (9 - 11 yrs) ______
Explorers (5 - 8 yrs) ______Other______
Number of Years and camps you have attended? ____ Amount enclosed with this application: $______
(NOTE: A non-refundable deposit of $ 10.00 is required with this application.)
Summer camp tuition’s are as follows:
Registration by June 1st: $150.00
After June 1st and Walk-ins: $175.00
RELIGIOUS INFORMATION
Current Spiritual Status:
____ Saved (Confessed sins, accepted Christ=s forgiveness)____ Sanctified
____ Baptized with the Holy Ghost____ Baptized in Water
Church Affiliation:
____ Member of the Church of God of Prophecy at ______
____ Attend Church of God of Prophecy at ______
____ Other ______
CHECK-OUT INFORMATION
Please list the names of persons other than parent/guardian to whom child may be released. For camper=s protection, camper will not be released to anyone other than those listed here or to the parent/guardian listed above.
1)______2) ______
3) ______4) ______
STATEMENT OF CERTIFICATION AND UNDERSTANDING
I certify that all the information provided on this application is accurate to the best of my knowledge. I understand that in signing this application I am agreeing to abide by all the policies and disciplines of the camp, its administration, and staff personnel.
Camper’s Signature ______Date: ______
Parent’s Signature ______Date: ______
MEDICAL INFORMATION
Camper Name:______
Please indicate with a check mark any of the following medical problems that apply to the camper. If it is a current problem, please provide date of most recent occurrence; if past problem, give approximate date.
Epilepsy: ______Asthma: ______Rheumatic Fever: ______Fainting: ______
Convulsions: ______Tuberculosis: ______Diabetes: ______Sleep Walking: ______
Heart Trouble: ______Kidney Trouble: ______Serious Ivy, Oak or Sumac Poisoning ______
Date of Most Recent Operations or Illnesses: ______
Date of most recent tetanus shot: ______
Allergic Reactions to: Bee/Wasp Stings: ______Penicillin: ______
Any other known allergy: ______
Specific activities to be restricted: ______
Are you presently under medical care? ______If so, describe: ______
______
Are you presently taking medication? ______Please indicate any medication taken by the camper on a regular basis ______
(All medication must be given to the camp nurse. No medication will be administered to any camper or staff unless in its original container or package)
Are you presently on a special diet? ______If so, describe: ______
Please list below any additional problems (physical or emotional) that you feel the camp staff should be aware of.
All information on this form is considered confidential.
__________
______
Name of Physician: ______Physician=s Telephone: ______
In the event of accident, injury, sickness, or any medical emergency, I understand that reasonable effort will be made
by the camp staff to contact me (parent or guardian of camper). If I am not contacted, I hereby give permission to
the camp director and physician selected to secure proper treatment for, to hospitalize, and order injection, anesthesia,
or surgery for the camper.
Camp Policy: All campers will be checked for head lice before registering for camp.
SIGNATURE OF PARENT (OR GUARDIAN) AND DATE: ______
IMPORTANT: Camp applications cannot be processed unless this form is completed and signed.
Please list the name of AYOUR@ insurance company (Hospitalization/Medical) and policy number. Camp insurance
is secondary.
NAME OF INSURANCE CO.: ______POLICY NO.: ______
The Church of God of Prophecy Camp accepts applications on a first-come, first-served basis, without regard to race, creed,
color, sex, or national origin.
Make Checks payable to: Church of God of Prophecy
Mail Application to: Church of God of Prophecy
CAMP
P. O. Box 370
Lizella, GA 31052-0370
FOR OFFICE USE ONLY
Date application received: ______Deposit ______Check/Money Order # ______