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Home
Profile
About the Diocese
The Episcopal Church in South Dakota
The Episcopal Church
Annual Convention
Niobrara Convocation
Local Congregations
Companion Diocese
Ecumenical Relationships
Episcopal Search
Who We Are
Meet Our Bishop
Diocesan Staff
Diocesan Clergy
Committees and Elected Officers
What We Do
Thunderhead Episcopal Center
Camp Remington
Discernment and Spiritual Formation
Ministerial Education and Leadership Development
Niobrara School for Ministry
Outreach and Mission
Episcopal Church Women
Resources
Consitutions and Canons
Diocesan Documents
Forms and Applications
Native American Resources
Open Clergy Positions
Genealogical Research
Featured Publications
Liturgical Resources
Church Publishing
Glossary of Episcopal Terms
News
Current Issue
Church News Archive
Subscribe to the Church News
Calendar
That they might have life
2018 9th and 10th Grade Camp Registration
Camper's Name
*
Camper's Name
Please provide your camper's full legal name. Since your camper will be entering 9th or 10th grade next year, he or she will be attending 9th and 10th Grade Camp from Sunday, June 10 – Saturday, June 16.
First Name
Last Name
Camper’s Date of Birth
*
Camper’s Date of Birth
MM
DD
YYYY
Camper's Sex
*
Male
Female
Camper's Mailing Address
*
Camper's Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Camper's Parent/Legal Guardian
*
Camper's Parent/Legal Guardian
Please provide the full legal name of this camper's parent or legal guardian.
First Name
Last Name
Parent/Legal Guardian Phone Number
*
Parent/Legal Guardian Phone Number
(###)
###
####
Parent/Legal Guardian Email
*
Who should be contacted in case of an emergency?
*
Parent/Legal Guardian
Someone Else
Emergency contact (if other)
If someone other than the parent/legal guardian is the camper's emergency contact, please give his or her full name and phone number here.
Please tell us about the camper's health:
*
Does the camper have any dietary restrictions, allergies, or restrictions on activities? If so, please describe them here.
If camper takes medications of any kind:
Please provide here a list of medications with instructions as to the method and dosage for administering them. Medications must be turned over to camp staff upon arrival.
Camper's Health Insurance Provider
*
Please give the name of the camper's health insurance provider.
Camper's Health Insurance Policy Number
*
Transportation Disclaimer
*
I understand that I have registered my camper after the May 15th ride deadline and that I am responsible for my camper's transportation to and from camp.
Cost of Camp
*
The cost of 9th and 10th grade camp is $150. We want everyone to come to camp. No one should feel that he or she can not come to camp because he or she does not have the money. The Diocese subsidizes the operations and staffing of its camps to keep the camper fees minimal. Please select the payment option that best describes your situation. If you can contribute some of the cost of camp or do not need a scholarship, instructions for how to pay the registration fee will be included in the registration confirmation.
Camper will need a full scholarship to come to camp.
Camper will need a partial scholarship to come to camp.
Camper does not need a scholarship to come to camp
Further Information
If you need to provide any further information that relates to the camper that has not been addressed on this form, please provide it in the area below.
Camper Behavior Expectations
*
No drugs, tobacco, or anything that can be considered a weapon are to be brought to camp. Because camp is a place of spiritual community and renewal, we will ask campers to turn in all electronics, including cell phones, mp3 players, and e-readers, so they can be present at camp. We will also insist that campers refrain from inappropriate sexual or violent behavior while at camp. And, of course, campers are to be respectful of everything and everyone at camp.
I, as the parent or guardian, have read, understood, and fully accept the Camper Behavior Expectations and agree to communicate them to the best of my ability to my child.
Parent/Guardian Release
*
By selecting the box below, you as the parent or guardian affirm: the health history for this child is correct to the best of my knowledge. This child has permission to attend camp and engage in all activities, except as noted. If I cannot be reached in an emergency, I hearby give permission to the physician selected by the Camp Director or Nurse to hospitalize, secure treatment, and to order injections, anesthesia, or surgery for my child. I further understand that completion of this registration grants permission to use photos of my child, taken at camp, for publicity purposes.
I, the parent or guardian, have read, understood, and provide my full permission for the above stated release.