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					                        Pomme de Terre Camper Registration Form summer camp 2012

                                                                                                                                   Camper Registration Form: Last name________________________________________Church__________________________Pastor’s #: _______________
                 Camp Fee: $                               Completed Registration Form Due ___________
Please circle t-shirt size for camper (t-shirt is included in cost of camp):
Youth Small                 Youth Medium               Youth Large                Youth X-Large

Adult Small        Adult Medium     Adult Large       Adult XL         Adult XXL
Camper Info                                                            Pastor’s Recommendation
          Male                 Female                                  I recommend this camper for participation in camp this
                                                                       year and understand that if it should become necessary
                                                                       for this camper to be sent home, I agree to pick them up
Address:                                                               and return them home if parents are unable to do so.
City:                                       Zip:                       Church ph                           Cell
Home Phone:                                                            Pastor’s Signature:
Grade:                         D.O.B.                                                                              Date
Home Church Name                                                         Important Information YOU Need to Know:
Church Phone                                                                     Camp cost and completed registration is due
Is camper on Prescription Medication?       Yes       No                          by deadline set by your church.
Camper’s Declaration:
                                                                                 Please make all payments payable to your
I will fully cooperate with the staff, rules and program                          church, your church will then make all
established for the camp so as not to discredit my                                payments to camp. No personal checks can
parents, my church or myself.                                                     be accepted at camp.
        Check here if you agree to the above terms.
                                                                                 Make sure that you completely fill out BOTH
Camper signature:                                                                 sides of this form.
Parent/Guardian Info                                                             Please make a copy of your medical
                                                                                  insurance card and attach it to this form.
Mother/Guardian Name:
                                                                                             Camp Activities
Address (If different from above)
                                                                       Every day at camp, campers will spend time
                                                                       participating in activities they choose. Campers will
City:                                       Zip:                       need to sign up for some activities while at camp and
                                                                       participation will be based on availability. Parent or
Home Phone:                                                            guardian please read through ALL activities and list
Place of Employment:                                                   any activities in the releases section that you DO
                                                                       NOT wish your child to participate.
Business Phone:
Father/Guardian Name:                                                            Skateboarding
                                                                                 Free time
Address (If different from above)                                                Team Building Games
                                                                               Other activities will include but not limited to:
City:                                       Zip:                               Sand Volleyball- Basketball- Softball- Hiking-
Home Phone:                                                                          Frisbee-- Zip Line- Tug O War-
                                                                                        Flag Football-Water Slide
Place of Employment:
Business Phone:
                   Summer Camp 2012 Activity Permission, Release and Medical Power of Attorney
1) I, the lawful parent or guardian of                                            (The “child”), give permission for my child to
participate in Summer Camp 2012 at Camp Pomme de Terre and release from all liability and indemnify the International
Church of the Foursquare Gospel, and its Directors, Officers, council, agents, representatives, volunteers, and employees
including the camp Director and staff, the sending church and Camp Pomme de Terre (“Church”) from any and all liability,
claims, judgments, cost or expenses, including attorney fees, arising out of any damage, injury or illness incurred or caused
by my child while participating in or traveling to or from the activity or off site activity, or otherwise in Church custody. I
understand the risks in these activities, including the possibility of unforeseen hazards, serious injury or death. I certify my
child is able to participate in this activity.
2) I agree to instruct my child to cooperate with the Church and its representatives in charge of the activity and understand
my child may be prohibited from participating and/or sent home for any failure to follow the rules established by the church. I
understand that I will be responsible for my child’s actions and will be held financially responsible for any damage done by
my child.
3) I appoint Church representatives who are acting as leaders, or designated by such leaders, as my attorney in fact to act
for me in my name and on my behalf, in any way that I could act if I were personally present, with respect to the following
matters if any injury, illness or medical emergency occurs during the activity, related travel or while my child is in Church
        A) To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions
        pertaining to any emergency transportation, medications, medical or dental treatments, diagnostic or surgical
        procedures or any other emergency actions as our medical attorney-in-fact shall deem necessary or appropriate for
        the best interest of the child.
        B) I understand the Church will make a reasonable attempt to contact me as soon as possible in the event of a
        medical emergency involving my child.
4) My child is to be excluded from the following activities
And/or from release to the following persons
                                                  (IF LEFT BLANK, NO ACTIVITIES OR PERSONS ARE EXCLUDED)
5) I agree that the Church may use my child’s and/or my own name, voice, portrait, photograph or image for promotional,
website, office or any other church related purposes. These may be used in any broadcast, telecast, digital or print medium,
including video images, photographs, pictures or renderings, audio recordings or other likeness in combination or alone.

I will notify the Church immediately of any change in the information presented and agree it is valid until revoked in writing
by me. I have carefully read this statement, and my signature acknowledges that I fully understand the content and

Signature of Parent or Guardian (Individually and as parent/Guardian)              Date
  Medical Information- Completed by Parent or Guardian – Please Print (attach copy of medical card to this form)

Child’s Name                                                                          Birth date

Allergies (medications/foods/insect allergies/etc)            Medications student is taking (on going basis)

Chronic/other medical conditions (e.g. epilepsy, diabetes, asthma, heart, depression, etc.)

Medical Insurance Company                                                    Policy Number

Parent Guardian name (print)                                                 Emergency phone number

Parent Guardian name (print)                                                 Emergency phone number

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