2018 Harrisburg Area Confirmation Camp Saturday, June 16 - Friday, June 22. Registration Information

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1 2018 Harrisburg Area Cnfirmatin Camp Saturday, June 16 - Friday, June 22 Registratin Infrmatin The buy in fee fr cngregatins is $340 fr 2018 and is due n April 15, Registratin Fee fr Pathfinders, Saints, GGP, MBC, LT, CLAY, and Staff is $340 per persn. Cunselr Registratin Fee is $200 per persn. (See separate instructins fr Cunselr inf) Please submit registratin infrmatin by April 15, Please be sure yu are using 2018 frms ld frms will nt be accepted. Registratin frms are available at the camp web site: harrisburgcnfirmatincamp.rg Use the same frm fr all registrants except staff (new registratin frm fr 2018). Please be sure t check participatin level. All yuth shuld register with their grade level even if they have nt cmpleted the prir year f camp. All participants must submit a waiver f risk. This is nt ptinal, n waiver, n attendance. Cunselrs and staff must submit the fllwing infrmatin in rder fr camp t be in cmpliant with the Pennsylvania Child Prtective Services Law (CPSL) revised in July f New staff and cunselrs will need t secure the fllwing clearances and submit by April 15, 2018: Pennsylvania State Plice Criminal Recrd Check ( Pennsylvania Child Abuse Histry ( Federal Bureau f Investigatin Criminal Backgrund Check r Signed Affidavit if a resident f Pa fr 10 years Registratin infrmatin shuld include: Registratin Frms fr all staff and cunselrs (including medical infrmatin) PA Child Prtective Clearances as listed abve. A list f all participants (including staff and cunselrs) by Curriculum/Track that includes: Name, address, T-shirt size, phne and (Example prvided n back) One Cnslidated Check is preferred frm each cngregatin and shuld be included with the registratin infrmatin made payable t: Harrisburg Area Cnfirmatin Camp Registratins will be prcessed in the rder received. All frms must be submitted. Please d nt submit a list nly. Registratins will nt be accepted withut payment. Please check that all the infrmatin n yur frms is cmplete befre submitting. Questins? Please cntact: Sarah Thmpsn by (scracraft@gmail.cm) r phne ( ). Send cmpleted registratin package t: Sarah Thmpsn 5525 Partridge Curt Harrisburg, PA Please nte: (Over)

2 *If there is a prblem submitting yur camp payment with registratins please cntact the directr. Please d nt assume that it is k t submit yur payment in June. *Yuth frm the same cngregatin are usually nt hused tgether. Please tell parents nt t request same cabin assignments. If YOU have a reasn t request tw campers t be tgether, please talk t Sarah Thmpsn by nte, phne r . If yu have a reasn fr tw t be separated, please infrm Sarah with that infrmatin as well. *N persnal refunds after May 15 th. Exceptins may be granted fr unusual circumstances. Sample Registratin List submissin: 2018 HARRISURG AREA CONFIRMATIONCAMP REGISTRATION Cngregatin Name Here Male/Female Shirt Size Name Track Address City, State, Zip Included in Check? Or Paid Camp directly? All frms included?

3 HARRISBURG AREA CONFIRMATION CAMP 2018 STAFF REGISTRATION FORM PLEASE NOTE: ALL APPLICANTS MUST COMPLETE THIS FORM PLUS RISK WAIVER FORMS AND CHILD PROTECTION CLEARANCES. NAME First Last ADDRESS Number and Street City, State and Zip Cde PHONE: HOME CONGREGATION YEARS OF MEMBERSHIP CONGREGATION YOU ARE REPRESENTING AT CAMP IF DIFFERENT FROM ABOVE: FEMALE MALE CLERGY LAY PERSON OTHER I WANT A STAFF T-SHIRT: YES NO PLEASE CHECK SIZE: S M L XL XXL ARE YOU A PREVIOUS PARTICIPANT OF CONFIRMATION CAMP? YES NO NUMBER OF YEARS CONTACT IN CASE OF EMERGENCY: NAME: ADDRESS: PHONE: RELATIONSHIP IS THIS PERSON PRESENT AT CAMP? YES NO MEDICAL INFORMATION ARE YOU TAKING ANY MEDICATION OF WHICH THE NURSING STAFF SHOULD BE AWARE? YES NO IF YES, PLEASE LIST: ARE YOU ALLERGIC TO ANY MEDICATION? YES NO IF YES, PLEASE LIST: DATE OF YOUR LAST TETANUS SHOT? DO YOU HAVE ANY PHYSICAL PROBLEMS THAT WOULD PREVENT YOU FROM ENTERING FULLY INTO THE CAMP PROGRAM? YES NO IF YES, PLEASE DESCRIBE: PLEASE LIST ANY DIETARY RESTRICTIONS/FOOD ALLERGIES:

4 MEDICAL INSURANCE INFORMATION NAME OF INSURANCE COMPANY ID # GROUP # HMO PLAN YES NO NAME OF SUBSCRIBER RELATIONSHIP PLACE OF EMPLOYMENT EMPLOYER S ADDRESS Nte: In the event f an emergency illness r injury requiring medical attentin, the patient s insurance will prvide the primary cverage. THE FOLLOWING ARE THE EXPECTATIONS FOR ALL STAFF AT THE HARRISBURG AREA CONFIRMATION CAMP: I WILL SHOW THROUGH MY ATTITUDE AND ACTIONS A WILLINGNESS TO EXPRESS AND SHARE MY FAITH WITH THE YOUNG PEOPLE OF THE CAMP. I WILL PARTICIPATE FULLY IN THE ACTIVITIES OF THE CAMP, ESPECIALLY WORSHIP AND STAFF MEETINGS. I WILL WORK COOPERATIVELY WITH THE OTHER STAFF. I WILL FOLLOW ALL THE RULES OF THE CAMP. I WILL REFRAIN FROM ENGAGING IN ANY PHYSICAL, EMOTIONAL, OR SEXUAL HARASSMENT. I WILL REMAIN AT CAMP FOR THE ENTIRE WEEK EXCEPT IN THE CASE OF AN ACTUAL EMERGENCY. I WILL READ AND BE FAMILIAR WITH THE CAMP STANDARDS MANUAL AND KEEP MY MANUAL CURRENT WITH NEW POLICY CHANGES. I INTEND TO PARTICIPATE IN CAMP FOR THE ENTIRE WEEK. YES NO (IF NO, PLEASE INDICATE YOUR CONFLICT AND WHEN YOU WILL NOT BE ABLE TO PARTICIPATE IN CAMP: ) YOUR SIGNATURE BELOW INDICATES YOUR COMMITMENT TO ABIDE BY ALL OF THE ABOVE EXPECTATIONS. SIGNATURE OF APPLICANT DATE REVISED: 1/2018

5 REVISED: 8/2012 HARRISBURG AREA CONFIRMATION CAMP Acknwledgement f Risk, Release and Hld Harmless Agreement (Adult Participant) Name f Participant: The Adult Participant agrees as fllws: 1. Assumptin f Risk. I understand that participatin in the Harrisburg Area Cnfirmatin Camp (HCC) invlves physical activities, including, but nt limited t swimming, utdr games, rpes curse and ther utdr camping activities as part f its utdr ministry prgram. I understand that these activities invlve risk f injury, and I knwingly and vluntarily assume the risk f engaging in activities n behalf f the Participant. I understand that participatin may include activities which may be hazardus and that these ptential dangers are part f and inherent t HCC s prgram. In sme instances, the activities cannt be made safer. I expressly assume the risk f injury r harm in these activities and vluntarily agree t the terms f the Release as stated belw. I further prmise and agree t fllw and t cmply with all instructins f HCC and its staff, emplyees, and authrized representatives. 2. Waiver and Release. In cnsideratin f the pprtunity t participate in the HCC prgrams and in recgnitin f the nature f certain f activities, the Participant specifically waives any and all claims, suits, causes f actin, actins, rights, expenses, damages f any kind, in law r in equity, fr any and all injuries that may arise during, result frm, r be therwise cnnected with Participant s participatin in HCC s prgrams. Fr thse same reasns, Participant further remises, releases, quitclaims and frever discharges the HCC, its Bard f Directrs, fficers, emplyees, staff, vlunteers, agents, and representatives frm any and all liability. 3. I authrize the HCC and its representatives t btain any medical treatment fr the named Participant that shuld appear necessary during his r her participatin in the HCC and that I will be respnsible fr the payment f any expenses assciated with the related illness r injury. 4. I agree and certify that I vluntarily signed this Agreement and I have read and fully understd the meaning f each f the terms f this Agreement. I intend t be legally bund by the terms f this Agreement. Signature f Participant Date (Revised August, 2012)