PWC Kids Camp 2022

Child's Infomation

Name

Birthdate

Gender

Male Female

Graded Entering

Shirt Size

Cabin Mate Preference

Legal Gardian

Name

This address will receive a confirmation email

Phone

Address

If, in an emergency, I cannot be reached, call (Please include Phone Number)

Medical Information

InformationAs legal guardian, I do hereby certify that this child is in good health and able to participate in all activities of the group:

Yes No

If no, what are the limits of his/her participation?

Current Medications

Any other allergies/medical issues to be aware of

Medical Insurance Company

Insurance Policy Number

As legal guardian of the herein named child, I hereby give my permission for him/her to participate in PWC activities and to travel to and from the location. I am familiar with and approve of the mode of transportation, leadership, departure, and return times and other circumstances of the trip.

Yes No

Whenever it may be necessary, I authorize the calling of a doctor and/or the providing of other necessary medical services and, unless covered by insurance, agree to pay for same. I understand that reasonable measures will be taken to safegaurd the health and safety of the child and that I will be notified as soon as possible in case of emergency. However, I do agree by my signature on this document to indemnify and hold harmless Plymouth Wesleyan Church, their employees, representatives, or group leaders from all liability, be it injury or illness, arising from this child’s participation in or attendance of PWC functions, no matter how caused.

Yes No

Note: There is also a Bair Lake Covid-19 Waiver and Release form that must be filled out. This can be found here.

Payment

Please select '$50 Deposit' fot the inital payment or '$250 (Full Registration)' to pay the full payment now.

Early registration was though April 30, 2022. As of May 1, the cost is now $250.
Note: All money is due by June 1, 2022

Payment $250 (Full Registration)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

PWC Kids Camp 2022

Description

Please Fix the Following