Sc Application 2009

SENIOR YOUTH CAMP REGISTRATION (Please Print) NAME___________________________________ AGE______SEX_____ ADDRESS________________________________ CITY______________ PHONE__________________________________ ZIP CODE__________

WESTERN DISTRICT SENIOR YOUTH CAMP GUIDELINES CAMP PRINCIPAL-TERRY DWORACZYK Santa Maria Fairgrounds – Santa Maria, CA AUGUST h-14th 2008

THIS CAMPER IS RECOMMENDED TO ATTEND SENIOR YOUTH CAMP.

_________________ BIRTHDATE (of Camper)

_________________________ PASTOR’S NAME

CHECK IN TIME Saturday, August –10:00 a.m. for pre-registered campers 11:00 a.m. for non-registered campers.

______________________ PASTOR’S SIGNATURE

This camper may participate in all camp activities. This camper may receive emergency medical treatment. Camp principal has my permission to sign for Medical Treatment.

CHECK OUT TIME Thursday, August 1th – 11:30 a.m. – 12:00 p.m. Immediately following the annual Sports Award and Inspirational Devotion NO CAMPER WILL BE PERMITTED TO CHECK OUT BEFORE THIS TIME

Under doctor’s care at present: Yes:_____ No:_____ For:__________________________________________________________ I take medicine at present: Yes:_____ No:_____ Yes:_____ No:_____ In the past three months I have been ill:

AGES 15-25 There will be no exceptions to this age span. Age will be determined by the camper’s age during the month of August. THIS CAMP IS FOR THE FELLOWSHIP AND DEVELOPMENT OF SINGLE YOUNG PEOPLE WHO ARE NOT PARENTS AND WHO HAVE NEVER BEEN MARRIED.

CHECK ANY BELOW THAT APPLY TO YOU Am a Diabetic Take thyroid Epilepsy Heart Disease Kidney Disease Take Insulin Take Asthma Drugs Can Run

Yes__No__ Yes__No__ Yes__No__ Yes__No__ Yes__No__ Yes__No__ Yes__No__ Yes__No__

Can go in water Yes__No__ Allergies: Yes__No__ to Eggs Yes__No__ to Tetanus Yes__No__ to Chocolate Yes__No__ to Penicillin Yes__No__ other Yes__No__ _______________________________

I affirm the above information to be true, and this camper may participate in all camp activities. I understand the Liability Release Form. DO NOT WRITE IN THIS SPACE

___________________________________ Parent or Guardian Signature

CAMP FEE $_________ DEPOSIT

$_________

BALANCE $_________

CAMP FEE IS $15.00 (Pre-Registered) $10.00 Fee for those who do not Pre-Register (There will be no prorate of fee for those attending a partial week.) Mail (Non-Refundable) Registration Fee of $0.00 Deposit And Application before July to Pre-Register

___________________________________ Camper’s Signature How long camper in Church? Sunday School Only? Does Camper have the Holy Ghost?

_________ _________

Send to: WDUPC YOUTH DIVISION SENIOR CAMP P.O. Box 547, Bakersfield, CA 93302 *Because of insurance and other controlling matters, there will not be any visitors (day or night) permitted on the grounds except for ministers and their spouses. No camper will be permitted to stay off campus. OUR DESIRE:

It is the desire of the Youth Leaders of the Western District that our Youth set a good example of the believer at all times, at home, at school, in our communities, at church and at our Youth Camps. OUR PURPOSE: It is our purpose to provide a balanced week that will be truly remembered by all as enrichment to their Christian life. Because of this, a full week is planned for you of…Spiritual enrichment..physical recreations….social activity and fellowship.

_________ THEREFORE, WE ASK ALL CAMPERS AND STAFF TO DRESS IN A GODLY MANNER. WE ARE TRYING TO PRESENT A CHRISTLIKE CAMP ATMOSPHERE.

CONCERNING OUR APPEARANCE TO THE STAFF: ALL THE STAFF MEMBERS WILL: 1. 2. 3. 4.

Be born again and church members in good standing. Be responsible leaders with Young people. Will accept all the guidelines set by the Youth Camp Committee. DRESS CODE: All Staff Members will be wearing sleeves to the elbow. The dresses of the ladies will be worn so as to cover their knees. Necklines will be modest and decent. Tight fitting clothes shall not be worn. No makeup or jewelry will be worn. No skirts or dresses with slits above the knees. Also, in keeping with the unity of the district, we ask that there be no mustaches or beards.

TO THE BOYS:

WESTERN DISTRICT OF THE UNITED PENTECOSTAL CHURCH MEDICAL TREATMENT CONSENT AND LIABILITY RELEASE FORM CALIFORNIA CIVIL CODE SECTION 25.8 It is my desire that I or my child/ward, participate in the activities of Senior Youth Camp therefore: I, the undersigned parent/guardian of _____________________________(Camper’s Name), do hereby authorize the adult sponsor of Senior Youth Camp or any responsible adult person bearing this written authorization, in to those said care the above mentioned minor child has been entrusted, to obtain proper medical care from a licensed medical or dental doctor or facility. The medical/dental care is to include, but not limited to, any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a licensed medical doctor or dentist.

In keeping with the spirit of the camp, they will not be wearing clothing that is tight fitting, pants must not be tight, but must come to the ankles, no shorts or cut-offs shall be worn. All shirts must have a sleeve length to the elbow. No plain white “T” shirts will be worn as a shirt. All boys will have a conservative haircut that becometh a Christian. In keeping with the unity of the district there will be no mustaches or beards allowed. No makeup or jewelry shall be worn. No punk styles of hair or attire will be allowed or any other styles that would be unacceptable to the Youth Camp Committee Members on the premises or the Camp Principal.

It is understood that this authorization is given in advice of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of said adult person to give specific consent to any and all diagnosis, treatment or hospital care which the aforementioned physician or dentist in the exercise of his judgment may deem advisable. This authorization shall include transportation to receive the medical or dental care.

TO THE GIRLS:

In the event of injury to myself, or my child/ward I agree that I /We and my health care insurer shall be financially responsible for any medical treatment required by myself, or child/ward as a result of any injury or illness suffered during his/her participation in any Senior Youth Camp related activities.

In keeping with the spirit of the camp, they will not be wearing clothing that is tight fitting or see-through. All skirts will cover the knees and all dresses or blouses must come to the elbow. No cap sleeves or sleeveless dresses will be permitted. Gauchos will not be permitted. Culottes will not be permitted since there are so many varied opinions among the various churches. No skirts or dresses with slits above the knees. Necklines should be decent and modest. No pedal pushers, slacks, shorts, etc. will be allowed. No makeup or any type or jewelry shall be worn. No punk styles of hair or attire will be allowed or any other style that would be unacceptable to the Youth Camp Committee Members on the premises or the Camp Principal. There will be no French manicures or fake fingernails of any kind and such like.

GENERAL CAMP RULES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11. 12.

13.

No one is to bring matches, fireworks, knives, radios, or any device that would be dangerous or disruptive to the camp. All campers commuting to and from the camp are under the responsibility of the parents and guardian. Campers are not allowed to leave the grounds after they register with camp director or head counselor. All campers are expected to be prompt at all meals and meetings unless excused by the camp director or head counselor. All campers are required to attend all classes, chapel, recreational activities, and evening services. Boys are not permitted to enter the area of the girls’ dorms, and girls are not permitted to enter the area of the boys’ dorm. This also means they should not be in the area of the other’s baths or showers. All athletic equipment (personal or camp) and facilities are under control of the recreation director and may only be used as instructed by the director. Every staff member and camper must be responsible for his or her own bedding and personal property. All should give respect to the camp facilities and property of others. Any camper defacing any property or tampering with property of another must pay the damage incurred and can be expelled immediately. Absolute quiet and reverence is expected from every camper during chapel, classes, and services. Enter these sessions with a spirit of reverence, and leave as orderly and quietly a possible. These services should be high moments of inspiration and encouragement. Staff and campers are required to stay in their dorms each night. No lights or noise, which disturbs others, will be permitted. All campers are to remain in their assigned areas of sleeping. No switching is permitted without consent of counselors and the head counselor. In the interest of protecting the privacy of each camper, image technology (still and video) shall not be used as such in bathrooms, showers, and dorm areas. Failure to comply with this policy may result in the confiscation of said devices till the end of camp and deletion of the content of said devices.

IT IS MANDATORY THAT ALL CAMPERS HAVE THEIR PASTOR’S RECOMMENDATIONS TO ATTEND AND THE PASTOR’S SIGNATURE ON THE REGISTRATION FORM. PASTOR: TO FULFILL OUR PUPOSE AND DESIRE OF THIS CAMP, IT IS MANDATORY THAT ALL PASTORS SENDING CAMPERS MUST GO THROUGH THE DRESS CODE RULES COMPLETELY WITH PROSPECTIVE CAMPERS PRIOR TO THEIR ATTENDANCE AT CAMP, IF ANY QUESTIONS PLEASE CONTACT THE CAMP PRINCIPAL.

FINANCIAL RESPOSIBILITY

RISK I am aware that these activities may involve some hazards. I have considered these risks and I still wish myself, or my child/ward to participate. Furthermore, I agree not to bring legal action against the Western District of the U.P.C., staff or sponsors as a result of any injuries suffered in the course of his/her participation.

DISPUTE In the event a dispute arises between myself and The Western District of the U.P.C. concerning injuries to my child/ward, then I agree that a Christian arbitrator acceptable to both sides shall resolve the dispute. The cost of the arbitrator is to be shared equally by the parties. All applicable statutes of limitation shall apply and arbitration must be requested within the appropriate period in order to reserve a right to recovery.

TERM OF AGREEMENT This authorization will remain in effect while myself, or the minor above is in route to or from or involved or participating in any program or activity authorized by the Western District of the U.P.C., unless revoked by the undersigned in writing and delivered to the agent of the Western District of the U.P.C.

Date

Signature

Relationship

Address

City

State

Phone (Day)

Phone (Night)

Medical Ins. Co.

Doctor’s Name

Doctor’s Phone

Group Cert. Or I.D.

Zip

Special Health Instructions: ___________________________________________________________________ ___________________________________________________________________