The. Camp Impact 2018 July East 1100 Rd. - Checotah, OK Teen Camp [Grades 6-12] July 9-12 Cost $165 With T-Shirt $175

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1 July East 1100 Rd. - Checotah, OK kids Camp [Grades K - 5] July Cost $130 With T-Shirt $140 PCG STUDENT MINISTRIES Teen Camp [Grades 6-12] July 9-12 Cost $165 With T-Shirt $175

2 THIS FORM AND A NON-REFUNDABLE $50 DEPOSIT IS DUE BY JUNE 15, TO RESERVE YOUR SPOT Teen Camp - grades 6-12 July 9-12 cost - $ With T-shirt $ Kids Camp - grades K - 5 July cost - $ With T-shirt $ Full Name Sex Male Female Grade / age Address Parents /Guardians Names City / State / Zip Phone Numbers - Parents/Legal Gaurdian Section # Home Church Senior Pastor s Name Senior Pastor s Signature To be filled out by individual/parent/guardian/family doctor of last immunization: / / Tetanus: / / Operations or serious illness: Penicillin or other drug reactions: List of any food allergies: Insurance provider: Policy # List medicine that is being taken: Contact Name in Case of Emergency Number Please read carefully I acknowledge and accept the risk of physical injury associated with participation in teen/jr. camp. I accept personal financial responsibility for any bodily or personal injury sustained during teen/jr. camp and promise to hold harmless the Pentecostal Church of God Oklahoma District and the Pentecostal Church of God Youth Ministry and it s representatives for any injury related to the activity. In case of emergency, I understand that every effort will be made to contact me. If not reached, I hereby give permission to the medical personnel selected by the camp leadership to hospitalize and/or secure proper treatment for the above camper. Camp insurance is secondary to a camper s personal insurance. I give permission for the use of any pictures or video taken of me or my child to be used by the Pentecostal Church of God Youth Ministry for promotions, advertisement, or web page use. I release to participate in all camp activities. Camper Signature Parent/ Legal Gaurdian Signature If camper is 18 or older, please continue to monitor/worker form to consent to background check.

3 THIS FORM AND A NON-REFUNDABLE $50 DEPOSIT IS DUE BY JUNE 15, TO RESERVE YOUR SPOT MONITORS & WORKERS - cost $135 - this form must be received by June 15th to be considered Are you Born Again? yes no Have you ever been dismissed from your duties for any reason? Are you Baptized in the Holy Spirit? yes no If yes, explain Do you use alcohol, drugs, or tobacco of any form? yes no Have you ever had any felony charges? Have you ever filled a position at camp before? yes no If yes, explain Are you a member of a PCG? yes no Have you ever been charged with child abuse? If yes, explain yes yes yes no no no Full Name Sex Male Female Grade / age Address Phone Number City / State / Zip Senior Pastor s Name Section # Home Church Senior Pastor s Signature To be filled out by individual/parent/guardian/family doctor of last immunization: / / Tetanus: / / Operations or serious illness: Penicillin or other drug reactions: List of any food allergies: Insurance provider: Policy # List medicine that is being taken: Contact Name in Case of Emergency Number Please read carefully of Birth / / Social Security # - - I,, hereby authorize the Pentecostal Church of God Youth Ministries and/or its agents to make an independent investigation of my background, references, character, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for the position I am applying for. I release Pentecostal Church of God Youth Ministries and/or its agents and any person or entity, which provides information pursuant to this authorization, from any liabilities, claims or law suits in regard to the information obtained from any and all of the above referenced sources used. Signature

4 THIS FORM MUST BE RECEIVED BY JUNE 15TH TO BE CONSIDERED TO WORK AT KIDS CAMP. The campimpact Director will contact you if you are approved and $130 will be due upon arrival YOU MUST BE ATTENDING TEEN CAMP TO JOIN! Must be between years old. Full Name Address Sex Male Female Parents /Guardians Names Grade / age City / State / Zip Phone Numbers - Parents/Legal Gaurdian Section # Home Church Senior Pastor s Name Senior Pastor s Signature Are you Born Again? yes no Have you ever filled a position at camp before? yes no Are you Baptized in the Holy Spirit? yes no Have you ever been dismissed from your duties yes no Do you use alcohol, drugs, or tobacco of any form? yes no for any reason? If yes, explain yes no PLEASE STATE THE REASON YOU WOULD LIKE TO SERVE AT KIDS CAMP PASTOR OR YOUTH PASTOR/LEADER RECOMMENDATION Please read carefully I understand that I am apart of a team that will be directly working beside the campimpact director and his staff. I understand that I have already been given the opportunity to be a camper and this week is about serving. I understand that the same rules that apply to campers apply to me except; I can have my cell phone. I understand that I can be sent home for not working. I understand that this is a privilege. I understand that respecting leadership, students, and campimpact staff is expected out of me. I acknowledge and accept the risk of physical injury associated with participation in the activity described above. I accept personal financial responsibility for any bodily or personal injury sustained during the activity and promise to hold harmless the Pentecostal Church of God Oklahoma District and the Pentecostal Church of God Youth Ministry and it s representatives for any injury related to the activity. In case of emergency, I understand that every effort will be made to contact me. If not reached, I hereby give permission to the medical personnel selected by the camp leadership to hospitalize and/or secure proper treatment for the above camper. Camp insurance is secondary to a camper s personal insurance. I give permission for the use of any pictures or video taken of me or my child to be used by the Pentecostal Church of God Youth Ministry for promotions, advertisement, or web page use. I release to participate in all camp activities. I approve of the APPLICANT to be a kids camp worker Parent /Guardian Signature Pastor Signature

5 Move ment The Registration form Fill out a separate form for teen camp and kids camp below and you MUST send a copy of this in with your forms! Church Name Please check which camp Teen Camp - grades 6-12 July 9-12 cost - $ With T-Shirt $ Kids Camp - grades K - 5 July cost - $ With T-Shirt $ Name boy/girl $50 deposit form t-shirt size Name monitor / worker cost: $135 teen worker cost: $130 (circle one) male/ female $50 deposit form t-shirt size 1. monitor / worker / teen worker 2. monitor / worker / teen worker 3. monitor / worker / teen worker 4. monitor / worker / teen worker 5. monitor / worker / teen worker

6 Camp Policies *Anyone who is 18 and over and who is staying the night must have a background check. *The Policies for campimpact have been established for the protective benefits of every person in attendance. *Any condition that may arise that is not covered by these rules shall be handled at the discretion of the Camp Executive Staff for a final decision. *Camp Executive Staff includes: camp director, assist. camp directors, and ym executives. *All persons who attend camp will be subjected to head lice examination. Any person who is found to have head lice must be treated at their expense before reporting to the dorm area. *Guests must register with camp staff upon arrival and sign out upon departure. No guest shall be allowed to spend the night without the camp executive staff approval, camp form filled out, and a small fee. Non-staying guests are welcome but must depart the grounds after the late night activities and in dorm is announced. *Vehicles are to be parked in designated area and not to be revisited unless authorized by camp staff. *No one should leave the campground without permission from one of the camp executives. Camp staff vehicles are to be used by camp staff only and no camper is to be on or in camp staff vehicles except in case of emergency. No person shall take a camper from the campgrounds except in case of emergency. *Willful destruction of personal or camp property will not be tolerated. The party responsible for the damage must pay any damages incurred before leaving camp. *No swapping or changing of dorms without the camps executive staff s permission. *All campers medications must be turned in to the camp nurse. All sickness should be reported to the camp nurse. *RESPECT is to be given to camp staff as well as to each other at all times. *The daily schedule must be followed. Attendance is required at services, classes, and activities. *Boys and Girls are not allowed in the dorm area of the opposite sex. When exiting the dorm area, exit in the proper direction as instructed by your dorm monitor. Violation of this rule will result in immediate action of the camp executive staff for review and may result in dismissal from camp without refund of camp fees. Enter only the dorm that you have been assigned. *All campers and camp staff must be dressed in compliance with the camp dress code before exiting the dorm. Shorts may be worn at all activities during camp except the evening services. Clothing MUST cover shoulders, back, sides, and navel at all times. No tight clothing. No tank tops. No apparel displaying or promoting secular groups, tobacco, alcohol, or inappropriate language. Evening services: All male persons Must wear jeans or slacks. All female persons Must wear modest dresses, modest skirts, jeans, or Capris. A modest skirt/dress is defined as a skirt/dress that touches the top of the knee while standing Modest jeans/capris for girls and guys covers their underwear at all times All shorts must be to your longest fingertip all the way around All apparel must meet the definition of modesty without accessories. ex: leggings, spandex, overlay (sheer material) *NUDITY- will not be tolerated! Modesty will be expected inside the dorms as well as outside the dorms. *No jewelry during sporting activities. *Campers are not allowed to have electronic devices during camp (if seen they will be taken away and given to their dorm monitor). *PRANKS- will not be tolerated! Absolutely no pranks of any kind!!! *PDA (public display of affection) will not be tolerated during camp. Stay in lighted areas of the campgrounds. *SWIMMING...Boys & girls will have separate swimming times. Boys & Girls must wear shorts and shirts (non-white) but girls must have some kind of swim suit underneath their shorts and shirt (non-white). *No vulgar or profane language. No alcohol, tobacco, or drugs. No knives or firearms. No fireworks. *When in dorm is announced, all persons including dorm monitors and helpers must go to dorms and remain inside their dorm. *All persons are expected to observe habits of personal courtesy and Christian conduct in order to protect the right of every person in attendance to enjoy a wholesome camp atmosphere of a Pentecostal Church of God Impact Student Ministries Camp. *Grounds and dorm must be kept clean. *Camp staff will inspect dorms before you are allowed to depart from the camp grounds.