Medical Treatment Release Form
Name: Date of Birth:
Insurance Co.: Policy #:
Teen’s Doctor: Phone ( )
Date of last Tetanus Shot: S.S. #:
Is your teen taking any medication? Yes No
Specify:
Is your teen allergic to any medication? Yes No
Specify:
Is your teen restricted to any physical activity? Yes No
Specify:
I, the parent of do hereby authorize the camp medic, any doctor and/or hospital to administer medical aid and treatment to my teen.
Parent Signature: Date:
Photograph Permission
Occasionally campers are photographed orvideotaped for use in communications and marketing materials. We ask that you sign below if your child has yourpermission to be photographedwhile attending camp at Shiloh Park Retreat and Conference Center.
Parent Signature: Date:
Rules for acceptance and participation in the camp program are the same for everyone without regard to race, color, sex, handicap or national origin. Any person who believes he/she has been discriminated against in any USDA related activity should write to: Secretary of Agriculture, Washington DC, 20250.
Northwest Indiana District
2006 Summer Camp
Grades 7 – 12
Presents…
Special Speaker: Larry Hess
Praise and Worship: PR Group from Olivet
Registration: Early $135 Late $150
Any registration not postmarked on or before
Monday April 3rd will pay late fee.
Registration forms will not be accepted after May 31st.
CAMP WILL BE CLOSED TO NON-CAMPERS THE WHOLE WEEK!
Send the completed registration and a $85 non-refundable, non-transferable to:
Noblesville Nazarene Church
Attn: John Mendenhall
1399 Greenfield Ave.
Noblesville, IN 46060
Larry Hess is the Director of Admissions for Southern Nazarene University in Bethany, Oklahoma. Prior to his current duties at SNU, Larry served in the business community and became a respected leader in hospital administration and business management.
Larry’s involvement in the community has included leadership on the Executive Council for the Oklahoma City/Metro area Fellowship of Christian Athletes, Habitat for Humanity, Oklahoma Business Men’s Association and the American Management Association. While working as a senior healthcare Administrator, Larry worked closely with the Oklahoma State Legislature dealing with state issues concerning healthcare/hospital issues. While attending Southern Nazarene University, Larry graduated with a Bachelor of Science degree in Criminal Justice and later earned a Master’s degree in the “Science in Management”.
Hess grew up in the eastern part of the United States and as a young man fell in love with the game of basketball. During his high school career, Larry was a dominant player at Point Pleasant High School, Point Pleasant, and W. Va. He received All-State honor his junior and senior year and his senior year was selected to an All America team. With numerous scholarship offers from NCAA and NAIA schools, Larry signed to play basketball with Southern Nazarene University and was a member of the 1981 NAIA National Championship team.
Larry’s involvement in youth and college ministry has spanned well over two decades. He began working with youth at Oklahoma City First Nazarene in 1981 and served on the youth staff for 10 years. Hess was then asked to serve as Pastor to University students. Larry served another 10 years with OKC First Nazarene until he accepted his current position at Southern Nazarene University. Larry presently serves the Lakeview Park Church of the Nazarene community as Pastor to College/University students. During his ministry with young people, Larry has led Work-n-Witness teams to 17 different countries, preaching and sharing the gospel with young and old, literally around the world.
A popular youth and college speaker and published author, Larry is a witty, down-to-earth communicator with a great sense of humor and a passion for growing the spiritual health within the lives of young people. He and his wife Nancy reside in Bethany, Oklahoma and have two children, Brooke (married) and Brady, student at Southern Nazarene University.
Bible, clothes (especially old ones that may get muddy), shoes, unmentionables, modest one piece swim suit, toothpaste, tooth brush, comb, soap, deodorant, shampoo, sleeping bag, pillow, towels, money for snack shop….
NO ELECTRONIC DEVICES OF ANY KIND WILL BE PERMITTED…(i.e. cell phones, TVs, N64 or the like, etc.)
NWIN SUMMER CAMP REGISTRATION
Local Church:
Name:
Street:
City: Zip:
Age: Grade Next Fall: Male Female
T-Shirt: M L XL Enclosed Payment: $
Roommates Preference:
I hereby state that I will abide by all camp regulations, respecting all leadership, and policies of the camp. I also agree to waive any and all claims against the district, church or any of the representatives, due to injury or damage that may be incurred to my property in connection with my stay at the camp. Recognizing that I am using the property of the Northwest Indiana District Church of the Nazarene, if I am found to be willfully damaging or destroying camp property, I will be held personally responsible for repair or replacement.
Camper’s Signature:Date:
By giving my signature, I will support the discipline of the camp; I will pick up my child, day or night, if he or she is a discipline problem; and I will be held personally responsible for repair and replacement if my child is found to be willfully damaging or destroying camp property.
Parent’s Signature:Date:
In case of sickness, notify:
Name: Relationship:
Hm. Phone: Wk. Ph.:
Campers are required to stay at camp the whole week. They must also stay in dorms with an approved sponsor. No visitors! We cannot guarantee roommates, but sending in applications early will be helpful.
If you have any questions, call John Mendenhall at 317-773-2411
Please fill back side out too (Medical Release Info.) Thank You!