Pastor’s Brunch R.S.V.P for the Pastor’s Brunch! Family InformationHow Many People Are You Registering For Camp?*Every person attending camp must be included on your application.Parent's / Guardian's Name* First Last E-mail Address* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Emergency Contact InformationEmergency Contact Name*If we are not able to reach you at the phone number you provided, who should we contact in the case of an emergency?Emergency Contact Phone Number*Camper #1 InformationName* First Last Gender*MaleFemaleBirthday* Date Format: MM slash DD slash YYYY Age*Please enter a number from 0 to 99.Please Select the Appropriate Program for this Camper*Pre-Camper (2 years-2nd Grade) $125.00Youth (3rd-6th grade) $200.00Student Leadership (7th-12th Grade) $165.00Adult Staff $150.00Medical InformationNote: Everyone must bring a copy, front and back, of your Insurance card. There is no copy machine at camp. Participants who have a condition that requires regular medication should bring an adequate supply in the original container. All medication must be turned in to the medical staff at check-in.Health Insurance Provider*Enter N/A or none if necessary.Health Insurance Policy / ID#*Enter N/A or none if necessary.Doctor's NameDoctor's Phone NumberPlease list any allergies, medical conditions, medications, or physical limitations that we need to be aware of.*If necessary, write none or n/a. Date of Last Tetanus Shot* Date Format: MM slash DD slash YYYY Camper #2 InformationName* First Last Gender*MaleFemaleAge*Please enter a number from 0 to 99.Birthday* Date Format: MM slash DD slash YYYY Please Select the Appropriate Program for this Camper*These prices reflect the early bird discount that ends on May 31st.Pre-Camper (2 years-2nd Grade) $125.00Youth (3rd-6th grade) $200.00Student Leadership (7th-12th Grade) $165.00Adult Staff $150.00Health Insurance Provider*Enter N/A or none if necessary.Health Insurance Policy / ID#*Enter N/A or none if necessary.Doctor's NameDoctor's Phone NumberDate of Last Tetanus Shot* Date Format: MM slash DD slash YYYY Camper #3 InformationName* First Last Gender*MaleFemaleAge*Please enter a number from 0 to 99.Birthday* Date Format: MM slash DD slash YYYY Please Select the Appropriate Program for this Camper*These prices reflect the early bird discount that ends on May 31st.Pre-Camper (2 years-2nd Grade) $125.00Youth (3rd-6th grade) $200.00Student Leadership (7th-12th Grade) $165.00Adult Staff $150.00Medical InformationNote: Everyone must bring a copy, front and back, of your Insurance card. There is no copy machine at camp. Participants who have a condition that requires regular medication should bring an adequate supply in the original container. All medication must be turned in to the medical staff at check-in.Health Insurance Provider*Enter N/A or none if necessary.Health Insurance Policy / ID#*Enter N/A or none if necessary.Doctor's NameDoctor's Phone NumberPlease list any allergies, medical conditions, medications, or physical limitations that we need to be aware of.*If necessary, write none or n/a. Date of Last Tetanus Shot* Date Format: MM slash DD slash YYYY Camper #4 InformationName* First Last Gender*MaleFemaleAge*Please enter a number from 0 to 99.Birthday* Date Format: MM slash DD slash YYYY Please Select the Appropriate Program for this Camper*These prices reflect the early bird discount that ends on May 31st.Pre-Camper (2 years-2nd Grade) $125.00Youth (3rd-6th grade) $200.00Student Leadership (7th-12th Grade) $165.00Adult Staff $150.00Medical InformationNote: Everyone must bring a copy, front and back, of your Insurance card. There is no copy machine at camp. Participants who have a condition that requires regular medication should bring an adequate supply in the original container. All medication must be turned in to the medical staff at check-in.Health Insurance Provider*Enter N/A or none if necessary.Health Insurance Policy / ID#*Enter N/A or none if necessary.Doctor's NameDoctor's Phone NumberPlease list any allergies, medical conditions, medications, or physical limitations that we need to be aware of.*If necessary, write none or n/a. Date of Last Tetanus Shot* Date Format: MM slash DD slash YYYY Camper #5 InformationName* First Last Gender*MaleFemaleAge*Please enter a number from 0 to 99.Birthday* Date Format: MM slash DD slash YYYY Please Select the Appropriate Program for this Camper*These prices reflect the early bird discount that ends on May 31st.Pre-Camper (2 years-2nd Grade) $125.00Youth (3rd-6th grade) $200.00Student Leadership (7th-12th Grade) $165.00Adult Staff $150.00Medical InformationNote: Everyone must bring a copy, front and back, of your Insurance card. There is no copy machine at camp. Participants who have a condition that requires regular medication should bring an adequate supply in the original container. All medication must be turned in to the medical staff at check-in.Health Insurance Provider*Enter N/A or none if necessary.Health Insurance Policy / ID#*Enter N/A or none if necessary.Doctor's NameDoctor's Phone NumberPlease list any allergies, medical conditions, medications, or physical limitations that we need to be aware of.*If necessary, write none or n/a. Date of Last Tetanus Shot* Date Format: MM slash DD slash YYYY Total $0.00 Parental Consent and Release of LiabilityYouth will only be released from camp to their parent or legal guardian unless otherwise authorized. Will a parent or legal guardian be picking this/these camper(s) up from camp?*YesNoPermission to Participate*As parent/guardian of the above named minor(s), I hereby grant permission for my daughter/son to participate in Westside Church of Christ’s Yosemite Bible Camp for the calendar year 2017. I AgreeMedical Authorization*I give my permission for the staff at Yosemite Bible Camp to give first aid to the above applicant and if necessary to take him/her to the doctor for treatment. I understand that I am finically responsible for the medical cost relating to the care and treatment of applicant. I further authorize YBC staff to disclose to, or obtain from, any physician, hospital or health care provider, any personnel and/or medical information deemed necessary for applicants medical care or treatment.I AgreeRelease of Liability*I agree that all activities are undertaken by the minor at the sole risk of the Minor(s) and myself, and that the Westside Church of Christ, the owners of the Property, and any other adult chaperones shall not be liable for any claims for injuries or damages whatsoever to person or property of the Minor(s) or myself arising out of or connected with the event or arising out of the use of the Property from now until December 31, 2017. I further agree to indemnify and to hold the Westside Church of Christ, the owners of the Property and any other adult chaperone assisting with the event harmless from all claims by or liability to Minor(s) and myself and hereby absolve them from any responsibility for personal injuries and/or property loss arising out of the event. I understand and agree to the policy and terms listed above and agree that any expenses incurred in necessary emergency or other medical treatment will be borne solely by the participant’s medical coverage and/or family.I AgreeToday's Date* Date Format: MM slash DD slash YYYY Total Camp FeesThere is a maximum of $500 per family. If your total is above $500, we will manually adjust your total to reflect this discount. You will receive an invoice for your camp fees via e-mail after the YBC staff has reviewed your application. Your spot at YBC is not confirmed until we have received your application and your payment.
