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									Form 1                                     Camp NewArk Registration Form
                                (All prospective campers must complete this form including sponsors/workers)

Camper Name: _______________________________________________________________

Church/City __________________________________________________________________
                                   Camp NewArk
                               389 County Road 4853
                                Newark, Texas 76071
                                   Instructions: Please print or type in INK. Do not leave anything blank! If
                                       your answer is “none” or “not applicable”, write that in the blank.
                                 Forms with missing information will not be accepted. Please, only one camper
                                                                    per form.
Name (last) _______________________________(first)________________________________

Address ______________________________________________________________________

City ____________________State _________ Zip_______________ Phone _______________

Parent Cell Phone#___________________________Other Phone#________________________

School grade just completed __________ Gender M                                  F        Birthdate _____/____/_____

Age Now ________                                                           Social Security # _______-______-_______

Person to notify in event of emergency:
Name__________________________________ Daytime Phone # _______________________

Evening Phone#___________________________Their Relationship to you?________________

ANY SPACES BLANK. (A copy of your insurance card may also be attached.)

Medical Insurance__________________________________ Group #__________________

Policy # ________________________ Company’s Address______________________________

City _____________________ State __________ Zip _____________Phone________________

Physical Limitations ( Asthma, diabetes, allergies, etc.), and / or special instructions (Allergic to
certain medications, food allergies, rare blood type, wears contacts, etc?)


Page Two
Form 1

Camper’s NAME____________________________________________________________

List all medication you take on a regular basis and/ or any you bring with you to Camp NewArk:

     1) ______________________________________2)_______________________________

     2) Date of last Tetanus Shot ______________________

Medical & Surgical Student Waiver: To be completed by parent(s) or legal guardian(s) of student under 18 years of age, OR
students over 18 must complete this waiver themselves.
*Mandatory Signatures Below

I, ______________________________________, parent and /or legal guardian of
______________________________, minor, hereby acknowledge that said minor is presently
under my care, custody, and control. Therefore, I give my child, the said minor, my express
permission to attend Camp NewArk between the dates of__________, and ____________.
I further expressly grant my permission for my child, said minor, to participate in all activities of
said camp. I have listed above said minor’s physical conditions or medical problems that may
need attention, and all medications regularly used by said minor. In the event there arises an
emergency necessitating medical or surgical attention, I hereby consent and give my permission
to the Camp NewArk staff, Stoneplace Ministries, or its representatives, or the Camp Sponsors
of the above stated dates, or any attending physician to make such decisions and to perform such
medical treatments and/or surgery upon said minor which may, in their sole discretion, be
necessary under the circumstances. I also consent and give permission for my child, at
his/her own discretion, to participate in counseling sessions while attending Camp NewArk. I do
release, acquit, discharge, and covenant to hold harmless the Camp NewArk staff, Stoneplace
Ministries, or its representatives, or the Camp Sponsors of the above dates, from any and all
action, damages, or liabilities arising out of the treatment of any sickness or accident incurred by
my said child during the above dates. I also give authority to Camp NewArk security staff, to
inspect my child’s room and belongings while at the camp for the safety and protection
of all CampNew Ark participants if unusual circumstances make such an inspection necessary. I
understand and agree that any and all legal disputes that may arise as a result of my child’s stay
at Camp NewArk during the above dates will have the local Wise County Court as the point of
venue. I understand that Camp NewArk staff may choose to use my child’s photo for
promotional purposes. I have read the Camp NewArk Policies & Procedures and understand
that my child will be dismissed from camp and sent home at my expense if he/she does not
adhere to the rules.

*Parent/Guardian Signature_____________________________________ Date ____________

Phone (______) ________/__________ AND/OR the signature of student 18 or
over in agreement with above waiver understanding that I am the person referred to as the
Page 3
Form 1

I am signing this contract committing myself to participate in the activities planned for this camp
and endeavor to make this the best week of my life. I promise to conduct myself in a Christ-like
manner, and have read the “Camp NewArk Policies & Procedures”.

STUDENT SIGNATURE________________________________________________________

My T-shirt size is _____________ Adult: S, M, L, XL                  Child: S, M, L

I agree to strive to reflect a Christ-like attitude while I serve as a sponsor. I realize that it is a
privilege and responsibility to serve children and youth and will do my best to be an example to
each person involved. I have read the Camp NewArk Policies & Procedures.

SPONSOR SIGNATURE_______________________________________________________

My T-shirt size is __________ Adult: S, M, L, XL, XXL

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