Youth Camp Camper Late Registration

Youth Camp will be held from June 21-24 at Crossway Church in beautiful Lancaster County, PA. This year's theme is "Heaven & Glory". Please fill out the registration below. (Parents are free, but must register). Youth Camp is for teens 13 years of age – those finishing 11th grade.

*Registration deadline is Sunday, April 30th. Late requests subject to availability and an additional $75 fee.

Parent Name*

First Last

Email*

Church Attending*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone*

Camper Name*

First Last

Gender*

Age (at camp)*

Birthdate*

Grade (just completed)*

PRIMARY EMERGENCY CONTACT (Parent/Guardian/Other Adult)*

First Last

Emergency Contact Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Number to be reached in an emergency*

Will the PRIMARY EMERGENCY CONTACT person be STAYING ON-SITE for the duration of camp?*

Yes
No

SECONDARY EMERGENCY CONTACT*

This adult will be on campus during Youth Camp, or geographically close by and can make decisions (medical or situational) if the PRIMARY EMERGENCY CONTACT cannot be reached. *DO NOT LIST A CAMP STAFF PERSON as a SECONDARY EMERGENCY CONTACT!

First Last

Cell Phone*

MEDICAL INFORMATION AND RELEASE

CONFIDENTIAL - We respect your privacy. This form is intended to provide necessary medical information to care for you/your child. It will be solely utilized by the Medical Team staff. It may also be reviewed by medical personnel, camp administration, office staff, and transportation personnel.

IMPORTANT: We ask that all parents review the "Parent Letter RE: Medication" before completing the medical info below. Click here to view.

If you have any medical questions, feel free to reach out to Lori Felizzi, our Youth Camp Medical Team Leader (717-344-4780).

CAMPER'S HEALTH CARE PROVIDER/MEDICAL INSURANCE:

CHECK HERE IF UNDERINSURED/SELF-PAY

Physician's Name

First Last

Physician's Phone

Medical Insurance Carrier

Insurer's Phone

Policy #

Group #

CAMPER'S HEALTH HISTORY

ALLERGIES (check all that apply)*

NONE
Animals
Hay Fever
Insect Sting
Medication
Other (list below)

Animals (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Animals

Please specify:

Hay Fever (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Hay Fever

Please specify:

Insect Sting (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Insect Sting

Please specify:

Medication (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Medication

Please specify:

Other (Indicate Severity)

Mild: No Medication required (ex: rash resolves on its own)
Moderate: Medication may be required (ex: Benadryl for hives)
Severe: Life threatening required to bring!

Other

Please specify:

Please bring NON-EXPIRED MEDICATIONS and give them to the Medical Team Leader during camp CHECK-IN.

FOOD ALLERGIES & DIETARY RESTRICTIONS*

NO food allergies or dietary restrictions.
YES, my child has food allergies or dietary restrictions.

Food allergy list

We need to know what foods cause what reaction and how dramatic the reaction is.
Please list food restrictions or allergies and any medical interventions necessary (epi-pen, Benadryl) in the space provided.

PLEASE NOTE: During mealtimes, your camper may choose accordingly from the foods served to ALL campers. There are NO SPECIAL MEALS made for those with food allergies. If they have special food they need to bring, YOU ARE RESPONSIBLE FOR PROVIDING REFRIGERATION IN THE FORM OF A COOLER.

DUE TO LIMITED SPACE, NO REFRIGERATION WILL BE PROVIDED BY THE CHURCH.

Tetanus Vaccinations

Has your child had any Tetanus vaccinations (including DTap, TDap, or TD)?
*NOTE: If Tetanus vaccination information is not supplied, your signature at the end of this form releases us from liability.

Date Administered - Type of Tetanus Vaccination

CONDITIONS & DISEASES (check all that apply)*

Behavioral Issues - Please Specify:

Other - Please Specify:

Additional Comments

MEDICATION TO BE GIVEN AT CAMP:

Check this box if you give permission for us to administer ibuprofen/acetaminophen.
NO ADDITIONAL MEDS WILL BE ADMINISTERED WITHOUT PRE-AUTHORIZATION prior to administration.

All medications must be in their original container, with original label, UN-EXPIRED, and turned in to Medical Team Leader during Camp Check-In.

Please DO NOT send non-prescription medication unless you/your child is able to self-administer (which will require reporting to the medical station or a parent/guardian on the premises to oversee administration). If a person is 18+ they can self-administer.

Any camper with a medical condition listed on this form that requires a prescribed medication, MUST bring that prescribed medication to camp or a doctor's note stating they no longer require use of that prescribed medication. Any extraordinary circumstances regarding this must be presented to the Camp Director and any alternate plans that require non-use of a prescribed medication must be PRE-APPROVED by the Camp Director after he has discussed it with the medical team. PLEASE DO NOT BRING YOUR CHILD TO CAMP WITHOUT THEIR NECESSARY, LIFE SUSTAINING MEDICATIONS.

Medication Information:

Please list any medications, the dosage, and how often it is needed (AM, Noon, EVE, BEDTIME, As Needed, etc)

PLEASE NOTE: THERE WILL BE NO PROVISIONS FOR INSIDE SLEEPING ARRANGEMENTS RELATED TO MEDICAL ISSUES. If your child has an extensive medical problem that warrants sleeping inside, parents will be required to secure alternate accommodations. Please contact Youth Camp staff to review your options.

Parents

Parents' Attendance (Parents are Free)*

Attending full-time (all meals and sessions every day)
Attending half-time (1-2 meals and sessions) each day
Attending part-time (1 meal and session) each day
Not attending/sporadic attendance (no meals etc)

Parent's Sleeping Arrangements*

Making Arrangements Off-Campus
Staying on Church Campus
Going Home Overnight

Team T-Shirt for Camper (free)*

Camp T-Shirt for Camper (free)*

Sweatshirt ($20)

Camping

Each Youth Camper is responsible for figuring out their own tenting arrangements. We realize that for many, these arrangements may still be in process. Please fill out the information below to the best of your ability at this time.

Are you supplying a tent for your teen?

Who is your teen planning to tent with?

Will your teen need to go off campus at any point during the event? If so, what dates and times?

*If your child will be leaving campus, notification is required by registration deadline: April 30th.

Comments / Questions

PHOTO/VIDEO PERMISSION*

I acknowledge that photos or video may be taken of my child.
I wish to “opt out”; please do not include my child in Youth Camp pictures or videos.

An online “Code of Conduct” agreement will be emailed (after registration closes) to the email you’ve supplied. Both camper and parent will need to read it and sign it within the timeframe stated in order for registration to be finalized. To preview that document, click here.

By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions in the Release of Medical Liability, Minor Participation and Adult Participation Agreements.

Signature*

REFUND POLICY

Registration closes firmly on Sunday, April 30th. After that we will be able to issue a 50% refund until May 30th. After May 31st, no refunds will be possible. Contact krista@crosswaypa.org to request a refund.

Camper Registration

Total

$0.00

Credit Card

Card Details

Cardholder Name

Email

This field is for validation purposes and should be left unchanged.

Youth Camp Camper Late Registration

Youth Camp Camper Registration

MEDICAL INFORMATION AND RELEASE

CAMPER'S HEALTH HISTORY

Tetanus Vaccinations

Parents

Camping

REFUND POLICY

For I Decided to Know Nothing Among You
Except Jesus Christ and Him Crucified

CONTACT US