DCY Camp Application

Youth Information

Name

Gender

M F

Address

Phone

This address will receive a confirmation email

Birth Date

Age

School You Attend

Grade in 2021-2022

Church you attend

Shirt Size

Parent/Guardian Information

First Name

Last Name

Phone

Address

Gender

M F

Home Church

City of Home Church

State of Home Church

Pastor's Name

Emergency Contact: (if same as parent, please note)

Relationship to Camper

List any medication which will accompany the child to the event - the dosage and the time(s) it is to be taken:

Date of last tetanus shot

I give my permission for my child to be given the following over-the-counter medications if needed

Ibuprofen Tylenol Antacid Pepto-Bismol Antihistamines Cough syrup None of the above

Describe any physical, emotional or mental limitations OR any food, medical or environmental allergies: (please be specific)

Signature (please type your full name)

Release of Claims, Hold Harmless

Dear Parent,
This form acknowledges that my minor will be traveling, with my authorization, with Youth Pastor Charlie Van Risseghem to the Spring Valley Ranch Camp on June 28th through July 1st. By signing below, I acknowledge that I am the legal guardian/parent of the minor listed below and I release Destiny Church International, Inc. from any and all liability.

Teenager's Full Legal Name:

I agree to allow my child to participate in the Spring Valley Ranch Camp.
This signature releases and agrees to hold Destiny Church International, Inc., its officers, and staff harmless from any and all liability for harm to teen or teen's personal property, resulting from illness, disease, civil unrest, or transportation accident or failure. Parents, individually and on behalf of his/her heirs, personally assumes all risks and liablities and agrees to indemnify Destiny Church International, Inc. against any liability, which might be assessed against it as a direct or indirect result of teen's participation in this trip.

I agree to allow my child to participate in the Spring Valley Ranch Camp's float trip.
This signature releases and agrees to hold Destiny Church International, Inc., its officers, and staff harmless from any and all liability for harm to teen or teen's personal property, resulting from illness, disease, civil unrest, or transportation accident or failure. Parents, individually and on behalf of his/her heirs, personally assumes all risks and liablities and agrees to indemnify Destiny Church International, Inc. against any liability, which might be assessed against it as a direct or indirect result of teen's participation in this trip.

I will also send my child with a life jacket if they need one.

Signature of Parent or Guardian (please type your full name)

Note: This form is intended for parental notification and protection of both Destiny Church International and its members. This form is required by administration for all non-Destiny Church International, Inc. activities. If you have any questions regarding this form, please feel free to contact the church administration at 918-259-9080.

Payment

This address will receive a confirmation email

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

DCY Camp Application

Description

Please Fix the Following