Breakthrough Summer Camp 2024 Registration - 6th-12th Grade

Student Name

Student's Current Grade

Student Gender

Male Female

Parent / Guardian Information

Parent Name

Parent Email

This address will receive a confirmation email

Parent Cell Phone

Parent 2 Name

Parent 2 Cell Phone

Health / Medical Information

Medical Insurance Company & Phone Number:

Medical Insurance Policy Number

Physician (name, phone number):

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff / volunteers should be aware, and what, if any action of protection is required on account thereof.

Please list all prescription medications. If none, write: none. *Most prescription medicines will be kept and administered by the nurses at camp. Include the name of the medication, dosage and directions for administering (time of day, as needed, with / without food, etc.)

Please list all over the counter medicines taken regularly or over the counter medicines that need to be administered by an adult. If none, write: none. Include the name of the medication, dosage and directions for administering (time of day, as needed, with / without food, etc.)

Does your student have any food allergies? If so, please list. If not, please write: none

Does your child have allergies to pollens, medications, insect bites, etc? If so, please provide details and if not, please write: none.

Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: asthma, epilepsy / seizure disorder, heart trouble, diabetes, frequently upset stomach, physical handicap?

Bridge Christian Church has permission to administer

Ibuprofen / Advil Tylenol Neosporin

Is your student able to swim?

If parents are not able to be reached, please list an emergency contact name, phone number, and relation to student.

Release Form, Parent Signatures & Payment

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. If any of the above information changes, it is the responsibility of parent / guardian to notify the church of these changes.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Bridge Christian Church. I/We understand that there are inherent risks involved in any ministry or athletic event and I/we hereby release Bridge Christian Church, its pastors, employees, agents (Virginia Nazarene Retreat Center, Reeling & Rafting Company), and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Bridge Christian Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

If any student is found to need medical attention, Bridge staff will use the phone number listed on this form to contact parent/guardian ASAP. Please make sure you are constantly available during this week of camp.

By typing your name here you acknowledge this is your signature of acceptance of the liability waiver.

By typing your name here you acknowledge this is your signature and give permission to Bridge Christian Church staff and student ministry volunteers access to your student's health / medical information:

By typing your name here you acknowledge and agree that your student will attend Breakthrough from the beginning of our trip to the end, with the exception of emergency or other extenuating circumstances. Students will not be permitted to come late or leave early due to other commitments (sports, other trips, etc.)

Deposit Payment $50

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 17-21, 2024

This year's summer camp will be held at Virginia Nazarene Retreat Center in Buckingham, VA!! This camp is a 4 night, 5 day retreat that will function much like a MIX and MOVE event. There will be morning and evening sessions, small group breakouts, worship, prayer, and times for fun and fellowship. In addition, our main speakers for this camp will be Brad Tate and Markel Croston! We hope your student will consider joining us for this amazing event. Overnight accommodations will dorm style (bunk beds, bath houses, etc).

The dates for this trip are June 17-21 and it is open to all students currently in grades 6-12. Students who attend must stay from the beginning of the trip until the end, with the exception of emergency situations or extenuating circumstances. Due to the nature of the trip, it will not work for students to come late or leave early for other commitments (sports, other trips, etc.)

Cost for this camp is $350, however, each student will receive a $75 discount from our envelope challenge, which brings the cost to $275 per student. A $50 deposit is required when you sign up to secure a spot. Final payment will be due Sunday, May 26. We never want finances to be a reason your child cannot attend one of our retreats. If financial assistance is something you need, please contact Phillip Painter to work through your situation.

Breakthrough Summer Camp 2024 Registration - 6th-12th Grade

Description

Please Fix the Following