Minions: Take Me to Your Leader. Youth Camp: July Kids Camp: July T-Shirt is included in the Registration Fee! $255.

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1 Northern New England District Assemblies of God Early Bird Registration $ Deadline: 5/12 Regular Registration $ Deadline: 5/13-6/2 Late Registration $ After 6/2 T-Shirt is included in the Registration Fee! Camp is First Come, First Serve... Register Soon! Minions: Take Me to Your Leader Kids Camp: July Youth Camp: July MANDATORY! N.H. State law requires each camper to have a full medical examination within two years of the opening day of camp. This exam must be verified via the proper signature (See the Physician s Statement of Examination form). Call the District Office at (207) or nnedkb@maine.rr.com to see if there is a current Physical on file. Download the Physician s Statement of Examination from our website, complete with your Physician s Signature & Return with your Application. The AUTHORIZATION FOR TREATMENT on the bottom of the Statement of Health must be signed. All prescription medication must be brought to camp in their original containers with prescribed instructions. Our camping program is covered by a limited accident and liability insurance for the entire time campers are in our care.

2 Camp Registration Costs Check all that apply: Early Bird Registration for One Child - $255 Postmarked by May 12, 2015 Each Additional Child from same household - $230 each Name of 2 nd Child: Name of 3 rd Child: Name of 4 th Child: $275 Normal Registration - This applies to any and all registrations postmarked between 5/13-6/2. Each Additional Child from same household - $250 each Name of 2 nd Child: Name of 3 rd Child: Name of 4 th Child: Family Discounts Not Available After June 2. $305 Late Registration - Postmarked after 6/2 Applications received after date will only be accepted as accommodations permit. CAMP AMENITIES (included with Registration): T-Shirts, Swimming, Canoe/Paddle Boats, Archery, Tubing, Hiking, Late Night Bonfires, Game Room & Team Competitions. For An Additional Cost: (check choice) Paint Ball (Youth Camp Only) - $25 per player TOTAL AMOUNT ENCLOSED: $ NNED Summer Camps Shirts (included in registration price) - please indicate size: Kid s Med. (6-8) Adult Medium Adult Large Adult 2X Kid s Lg. (10-12) Adult Small Adult X-Large Adult 3X For Camp Office Use Only Check # Check Date Paid By Amount Due Amount Paid Received By Postmarked Send Completed Registration Form and Fee to: NNED Camp Ministries 501 Riverside St, Portland, ME

3 CAMP LOCATION: Rumney Bible Camp, White Mountain Retreat Center, 31 Gilford Ave., Rumney, NH NNED CAMP DATES (Camp Costs are Non-refundable, but are Transferrable) Camp Ages Date Kid s Camp 8-11 July Youth Camp July Questions about Camp? Call the Youth Department at (207) Instructions & General Information 1. Send registration form along with full payment, made payable to NNED AG, to 501 Riverside St, Portland, ME Camp fees include lodging, meals, camp shirt and recreational activities. Campers may wish to bring extra spending money for offerings, snacks, etc. A Camp Bank will be available at Kids Camp only. Camp Bank money can be deposited at the time of check-in, and will be available daily. 3. We encourage campers to register early to assure them a place at camp. All registrations are filled on a first-come, first-serve basis. 4. Arrival time is 3:00-5:00 PM on Monday. 5. Departure time is 12:00 PM (Please be prompt). 6. Facilities: All campers will stay in supervised dorms/cabins. Dorms/cabins are not air conditioned. 7. Mail: Daily Mail Call is a highlight of Camp. You may send mail with camper s name to: White Mtn. Retreat Center, PO Box 99, Rumney, NH Please write NNED Camp in lower left corner of envelope. Letters must be mailed one week prior to start of camp in order for the camper to receive it. DO NOT MAIL CAMP APPLICATIONS TO THE RETREAT CENTER! 8. Telephone: Campers are requested not to call home unless there is an emergency. Permission to use the camp phone must be approved by the Camp Director. Incoming calls are also discouraged unless there is an emergency. In case of an emergency, you may leave a message by calling the camp at (603) DIRECTIONS: From points south and east, take Interstate 93 Rumney to exit 26; west 5 miles to the traffic circle. Follow signs west towards Rumney on Route 25. Turn left at the first blinking amber light approximately 3 miles past traffic circle. Upon entering the grounds make a quick left to Wright Lodge. From Vermont and points west, take I-91 to Fairlee, VT (exit 15). Cross over bridge into Orford, NH. Take Route 25A east to Route 25 east. Follow to Rumney, turn right at second blinking amber light. Upon entering the grounds make a quick left to Wright Lodge. General Camp Rules 1. Campers are under the authority of the camp staff during their stay at camp. 2. Campers are not permitted to leave the camp unless a written request by a parent/legal guardian is presented at registration. 3. Campers must stay in their rooms after lights out. Any camper caught outside after this time without a proper reason will be sent home. 4. Campers are expected to conduct themselves in an appropriate manner at all times and to attend all scheduled activities. 5. Use of tobacco, drugs, alcohol or other illegal contents is strictly forbidden. 6. No profanity, disrespectful or crude conversation is to be used. 7. Turn in any IPods, electronic games, cell phones, etc. that you have brought to camp. They will be returned at Check Out time. 8. Keep your room clean. Room checks will be done during morning Chapel services. 9. Respect other camper s belongings. 10. Do not damage or deface any camp property. If something is broken, report it immediately. Unnecessary damage will be charged to the person(s) responsible. If the guilty person(s) cannot be found, the cost of the repair will be shared by each camper in the room. 11. Check Out at the end of the week at the registration table. Each camper will be free to go home AFTER their room has been cleaned and approved by the Camp Director. Please Note: Any prescription drugs brought to camp must be in their original bottle. No over-the-counter drugs allowed! These are provided at camp. Campers should understand that violations of camp rules may result in disciplinary action, the contact of their parent/legal guardian with the possibility of being sent home and forfeiting their camp fee. What to Bring: Modest Attire - T-shirts and shorts are acceptable. No tank tops or midriffs permitted, Shorts must be fingertip length from the knee. If you are not appropriately dressed, you will be sent back to your room to change. 1-Piece Swimsuits for girls, swim trunks for boys Sleeping bag or sheets, blanket, and pillow Personal Care items: Soap, shampoo, toothpaste, etc. Towels Baseball Glove Flashlight Raingear Bible & Notebook Sneakers Bug Spray Spending Money Camera Mark Your Belongings! We are not responsible for lost or stolen items. Please leave all valuables at home. What NOT to Bring: IPods Tank Tops Radios Sleeveless Shirts Electronic Games Tube Tops Firearms/Fireworks Strapless Dresses Tobacco Mini Skirts Cell Phones Pornography Illegal Drugs Short Shorts Knives or weapons Skorts Over-the-Counter Drugs Expensive Jewelry

4 2015 NORTHERN NEW ENGLAND SUMMER CAMPS Mark Week Attending: Entered in to the Computer Payment PAID In Full Reg. Complete Camper Has Arrived Signatures Complete Medical Papers/Insurance Info Confirmation Sent Pick-up Person Known KIDS CAMP: JULY (AGES 8-11) YOUTH CAMP: JULY (AGES 12-17) EVERY AREA OF THIS APPLICATION MUST BE COMPLETED! - If not...it will be returned and your child won t be registered until a completed application is received. First Name Mailing Address: Last Name: City/State/Zip: Home Phone: Grade Completed: Date of Birth: / / Age: Male: Female: Address to Confirm Camp: Parent/Guardian Name: Phone: Cell: Emergency Contact: Phone: Cell: Has camper been convicted of any crimes or currently on probation? Yes No If yes, explain PARENTAL AUTHORIZATION: This health history is correct as far as I know and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician in writing at the time of registration. I hereby release and waive any and all claims against the Northern New England District AG Camps, White Mountain Retreat Center, and its staffs arising from his/her participation in the Northern New England AG Camps. IN CASE OF EMERGENCY, I hereby give my consent, in the event that all reasonable attempts to contact me have been unsuccessful, for the administration of any treatment deemed necessary by the appropriate licensed physician, nurse, dentist or emergency personnel. I also hereby understand that if my child refuses to adhere to the camp policies listed herein, I may be called to bring him/her home immediately. I also hereby give permission to the camp counselor and/or other member of the camp staff to inspect the contents of any or all of my child s personal belongings, and to withhold and/or dispose of any improper or illegal contents. I also hereby give permission for my child to be transported off grounds to participate in the recreation activities of the camp program. I authorize NNED Camp Ministry to use my child s likeness in photographs or video in any and all of its publications and in any and all media pertaining to camp. I will make no monetary or other claims against NNED Camp Ministry for the use of such photos and/or videos. This record is confidential and viewed by appropriate staff only. Parent/Guardian Signature: x Date: / / EARLY DEPARTURE POLICY: Leaving camp early is only allowed in case of emergency. Only an authorized person designated on this form may remove a camper from camp only with proper identification. Please list authorized person(s) Is there anyone to whom we should NOT release your child? Please list complete name(s) I will abide by all camp rules. I understand violation of these guidelines may result in my immediate dismissal from camp at parent/guardian s expense. Signature of Camper: X Desired Roommate (Limit 2 Names): Please check with desired roommate to confirm they are listing you and the same week. Roommate MUST also pre-register. Church Name/City/State: Youth Pastor or Senior Pastor's Signature: X Camp Registration Credit Card Information: MasterCard Visa Discover Total Charged to Card: $ Name on Card: Card Holder Billing Zip Code: Expiration Date: Signature:

5 Northern New England District Council A/G 501 Riverside St Portland, ME Tel.: 1(207) / Fax: 1(207) SUMMER CAMP STATEMENT OF HEALTH PERSONAL INFORMATION: Full Name Birth date / / Sex Age 1. YES NO This is the Campers first year at camp. 2. YES NO Record of current physical is now on file at the District Office. IF YES to question 1, or NO to question 2, THE PHYSICIAN'S STATEMENT OF EXAMINATION BOX MUST BE COMPLETED BY YOUR DOCTOR. HEALTH HISTORY: Do not leave any lines blank. If not applicable, write "NONE". Nose Bleeds: Yes No ADD/ADHD: Yes No Seizures: Yes No Type: Aura: Diabetes: Yes No How Controlled? Insulin Oral Hypoglycemic Diet ALLERGIES TO (Please Be Specific): Medications: Environmental: Food: Type of Reaction: Type of Reaction: Type of Reaction: Head Aches Migraines Treatment: Asthma: Yes No Inhaler(s): Yes No Type(s) of Inhaler(s) and when used: Hearing Disability: Yes No Hearing Aids: Yes No Visual Disability: Yes No Correct With: Glasses Contact Lenses Other: HEALTH PROBLEMS: Bone/Joint: Yes No Stomach: Yes No Heart: Yes No Kidney: Yes No Lungs: Yes No Bowel: Yes No Blood Pressure: Yes No Other: Activity Restrictions? Yes No Reason: PLEASE CHECK MEDICATION AND INDICATE DOSE: 1. PAIN/HEADACHES: 4. SKIN TREATMENT: Acetaminophen (Tylenol): Neosporin Regular Strength (325 mg) How Many? Calamine Lotion Extra Strength (500 mg) How Many? Hydrocortisone Cream 0.5% Children s Chewable (80 mg) How Many? 5. COLD/COUGH: Children s Chewable (160 mg) How Many? Robitussin Ibuprofen (200 mg) How Many? Cough Drops 2. ALLERGIES (ANTIHISTAMINES): 6. SWIMMER S EAR: Claritin (non-drowsy): Auro-Dri Benadryl (Liquid): Sudafed: 3. STOMACH: PARENTS: IF YOU DO NOT FILL OUT THIS BOX, THE CAMP NURSE Mylanta: WILL CALL YOU FOR PERMISSION BEFORE GIVING YOUR CHILD ANY OF THESE OVER THE COUNTER MEDICATIONS. Tums: Imodium: AUTHORIZATION FOR TREATMENT: To my knowledge, the information contained in this health history form is correct and the person herein described has permission to engage in all prescribed camp activities, except as noted. I hereby give my permission to the medical personnel, selected by the camp director, to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization for the person named above. The completed form may be photocopied for trips out of camp. I also give my daughter/son permission to receive the above medication(s) when necessary during the week of Camp which will be administered by the Camp Nurse or her designee. PARENT/GUARDIAN'S SIGNATURE Physician s Name: Date Telephone:

6 PHYSICIAN'S STATEMENT OF EXAMINATION Mandatory New Hampshire State law requires All Campers and Camp Staff to have a physical within 2 years of the start date of camp! Current physical must be on file at the District Office. Patient's Name Special Medications Allergies Type of Reaction Treatment Given Physical Handicaps, Disorders, Diseases Restricted Activities Reason(s) Date of Birth IMMUNIZATION RECORD This Patient been immunized against the following (Please indicate the dates of immunizations): DPT: HepB: OPV: MMR: DT: Td: TB: New Hampshire statutes require the student to have documentation of immunizations to attend camp, except in the case of a Medical Exemption or an appropriate parental objection. If either is the case, please attach a signed statement stating the exemption or objection to this form. FEMALES ONLY: Has this person menstruated? If YES, is her history normal? Special Considerations Physician's Name Address: City State Zip Phone: ( ) Fax: ( ) Physician's Signature Date WHEN COMPLETED, PLEASE SEND THIS FORM TO: NORTHERN NEW ENGLAND DISTRICT A/G ATTN: YOUTH DEPARTMENT 501 RIVERSIDE STREET PORTLAND, ME OR FAX TO: (207)