Jr./Sr. High Retreat
January 26-28, 2018
OHIO VALLEY CHRISTIAN ASSEMBLY
39560 Rocksprings Rd. P.O. Box 548.Pomeroy, OH 45769.740.992.5353
Completed form and registration fee of $50.00 Due Jan. 19, 2018
Registration Form(Please print legibly)
Name:
Address:
City/State/Zip:
Phone:
Parent(s)/Guardian Names:
(Please include Parent(s)/Guardians phone numbers)
Emergency Contact:
Email Address:
Home Church Information:
(Minister’s nameand phone number)
Is the student likely to become homesick?Has the student been to O.V.C.A. before?
Yes [ ] No [ ] Yes [ ] No [ ]
Has the student been immersed into Christ? Yes [ ] No [ ]
Registration form along with $50.00 fee are to be sent to OVCA, P.O. 548, Pomeroy, OH 45769, by Jan. 19, 2018. Contact Ronnie Sisk (740) 992-5353 if you are unable to pay the registration fee. Please make your check payable to OVCA. Please note below if your church is helping with payment.
Amount Church is paying:Full: Half:Other:
Name of Church:
Parent/Guardian SignatureDate
January26-28, 2018 OHIO VALLEY CHRISTIAN ASSEMBLY
39560 Rocksprings Rd, P.O. Box 548 -- Pomeroy, OH 45769 -- Phone740.992.5353
ACTIVITY/MEDICAL RELEASE
NOTE: Parent/Guardian must complete, sign and return this form with the registration in order for the student to participate within the program.
Student’s Name:
Please mark any illnesses your student HAS had:
[ ] Mumps[ ] Chicken Pox[ ] Asthma[ ] Heart Disease
[ ] Measles[ ] Ear Infection[ ] Tonsillitis [ ] Rheumatic Fever
[ ] Other (please specify):
Please mark any allergies your student is susceptible:
[ ] Poison Ivy/Sumac[ ] Penicillin[ ] Hay Fever[ ] Bee Sting
[ ] Other (please specify):
NO student is to be brought to OVCA ill. ALL medications, prescribed or otherwise, must be left with OVCA’s agent to be dispensed according to the prescription/instructions. ALL medications must be in their original containers, no exceptions.
Please mark any medications your student may be given should the need arise:
[ ] None[ ] Tylenol[ ] PeptoBismol [ ] Benadryl
[ ] Aspirin[ ] Mylanta
For Emergencies Call: (Name(s) and Phone(s))
Physician’s Contact Information (Name and Phone)
Health Insurance Information:
Insurance Company:Policy Number: Policy Holders Name:
I understand that in an emergency, OVCA will make every effort to contact those people listed above. In the event that OVCA is unable to contact myself or the designated emergency contact, I give my permission to the medical professional selected by the camp management to secure treatment for the student named on this form.
I further understand that completion of this form, with my signature, grants the student named above participation in all OVCA programs including swimming pool, climbing wall, and any/all activities associated with this retreat. I release OVCA staff, faculty, officers and management from any liability and shall not be held responsible for any articles lost, stolen, or left at OVCA. OVCA has my permission to use any videos or photos taken of the student while participating in this camp program to promote the ministry of OVCA (including camp website, Facebook, printed media, etc.). OVCA insurance only assists medical injuries occurring during the duration of OVCA program. Individual insurance coverage will be primarily responsible for extended coverage and OVCA will be limited secondary coverage only.
Parent/Guardian SignatureDate