903 S Catherine Creek Rd. Ahoskie, NC 27910 www.csicministries.com I noli Hall Executive Pastor C: (252) 642-4550 csicfinance@gmail.com May 1, 2018 Dear Parent, Summer is quickly approaching. That means lazy days, pool parties, and...no school! Yikes! Let s take advantage of this opportunity to ignite your child s spiritual growth. This July, the NC Assemblies of God is hosting a summer youth camp! Youth (ages 13-17) may attend The Ohana Experience Summer Camp in Black Mountain, NC. There will be fun outdoor activities and inspiring speakers. Many adults can point to a summer youth camp experience as the biggest turning point in their relationship with God. For details please see the accompanying information. Do not let finances prevent your child from attending. Feel free to speak with me about special arrangements before the first deadline. To qualify for financial assistance your child must participate in the fundraisers. Yours in Christ, I noli Hall I noli Hall
PLEASE SIGN AND RETURN THIS COPY. Deadline 1: Permission Slips and Deposit Sunday June 10th An additional late fee of $10 will be assessed for applications and payments received after June 10th. Deposit Amount: $75 (non-refundable) Deadline 2: Full Payment Sunday July 15th Full registration before discounts is $300. Students who participate in fundraisers qualify for a rate of $199. Those who need special assistance should speak with Pastor I noli. Full registration: $199 (including deposit & help in fundraisers) Pay online! www.csciministries.com/summercamp (Or pay in the app and designate as Event Registration ) Turn in signed permission slip at church or email to csicfinance@gmail.com. What s included in my $199 registration: Registration Cabin Meals Transportation What s NOT included in my $199 registration: Extra activities: Putt-putt golf, disc golf, high-ropes course, ice-cream shop, coffee shop Transportation via Church Bus Meet: 8 AM on Tuesday July 17th at Carpenter s Shop Int l Church Return: Around 8 PM on Friday July 20th (time subject to change) Trip Leaders: I noli Hall (252-642-4550) & TBA Who Can Go Youth (ages 13-17) When Tue-Fri July 17-20, 2018 Where Ridgecrest Conf. Center 1 Ridgecrest Dr, Ridgecrest, NC 28770 I acknowledge and agree to the above stated policies. Parent/Guardian Date
PLEASE KEEP THIS COPY FOR REFERENCE. Deadline 1: Permission Slips and Deposit Sunday June 10th An additional late fee of $10 will be assessed for applications and payments received after June 10th. Deposit Amount: $75 Deadline 2: Full Payment Sunday July 15th Full registration before discounts is $300. Students who participate in fundraisers qualify for a rate of $199. Those who need special assistance should speak with Pastor I noli. Full registration: $199 (including deposit & help in fundraisers) Pay online! www.csciministries.com/summercamp (Or pay in the app and designate as Event Registration ) Turn in signed permission slip at church or email to csicfinance@gmail.com What s included in my $199 registration: Registration Cabin Meals Transportation What s NOT included in my $199 registration: Extra activities: Putt-putt golf, disc golf, high-ropes course, ice-cream shop, coffee shop Transportation via Church Bus Meet: 8 AM on Tuesday July 17th at Carpenter s Shop Int l Church Return: Around 8 PM on Friday July 20th (time subject to change) Trip Leaders: I noli Hall (252-642-4550) & TBA Who Can Go Youth (ages 13-17) When Tue-Fri July 17-20, 2018 Where Ridgecrest Conf. Center 1 Ridgecrest Dr, Ridgecrest, NC 28770 I acknowledge and agree to the above stated policies. Parent/Guardian Date
Waiver and Liability Release I, the parent (or legal guardian) of ( my child ), give permission for my child to attend the The Ohana Experience summer camp on April 27-28, 2018 in Ridgecrest, NC hosted by North Carolina Youth Ministries ( NCYM ), a ministry of the North Carolina Assemblies of God ( NCAG ). I understand that personal injury can and may occur to my child, and I hereby authorize Carpenter s Shop International Church, the youth ministry director (I noli Hall) or another appointed youth advisor, to seek and consent to urgent or emergency medical attention (including precautionary examination) for my child as needed and to be held harmless from liability whatsoever. This authorization includes my agreement to be liable for and pay all costs incurred in connection with such medical attention. I hereby release Carpenter s Shop International Church ( Carpenter s Shop First Assembly of God ), its employees, agents, and volunteers ( CSIC, et al. ) from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to and from this event. To the extent permissible by North Carolina law, this includes (but is not limited to) loss, damage, or injury (including death) due to the active or passive negligence of CSIC, et al. or otherwise. Carpenter s Shop International Church, its employees, agents and volunteers cannot be held responsible for the active or passive actions or negligence of the NCAG, NCYM, Ridgecrest Conference Center, or their employees, volunteers, agents, or affiliates whatsoever. Nor can CSIC et al. be held responsible for such actions of other youth whatsoever participating in the event (including but not limited to incidents during travel to and from the event). I understand that my consent and release of liability regarding this event extends to any and all travel, activities, and sites visited during the trip (including but not limited to excursions to the mall, recreational sites, restaurants, etc.). The following is all of the insurance information, restrictions, allergy, and medication information necessary for my child to receive appropriate medical care. Insurance company and policy number/information Allergies and/or Restrictions Medications and/or Medical Conditions I permit youth advisors to administer to my child: Tylenol Aspirin Aleve Ibuprofen Benadryl Other important information I give permission for my child to ride in any vehicle designated by CSIC, et al. while participating in and traveling to and from this event. I agree to accept full responsibility, financially or otherwise, for any damage my child may do to the property of Carpenter s Shop International Church, properties visited on outing, other s personal property, or vehicles used for transportation. I agree and consent to all of the above stated. Parent (or legal guardian) Signature Date
Student Information Form Please print legibly Student s Personal Information Last Name First Name Gender Age Birthdate Home Telephone Full Physical Address (& mailing if different) Student s Cell Phone Student s Email Parent s Cell Phone Parent s Email Father s Name Mother s Name (or legal guardian) (or legal guardian) School Grade Skills/Talents Emergency Information (2 contact persons are required) 1. Name Relationship Home phone Cell Phone 2. Name Relationship Home phone Cell Phone Allergies, illnesses, medications, or special notes: My child may take (check all that apply): Tylenol Aspirin Aleve Ibuprofen Benadryl I understand that personal injury can and may occur to my child in connection with Carpenter s Shop International Church (CSIC) activities, and I hereby authorize CSIC, the youth ministry director (I noli Hall) or another appointed youth advisor, to seek and consent to urgent or emergency medical attention (including precautionary examination) for my child as needed and to be held harmless from liability whatsoever. I further agree to be liable for and to pay all costs incurred in connection with such medical attention. I hereby release CSIC, its employees, agents, and volunteers from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child whether due to negligence or otherwise. This agreement persists as long as my child participates in any CSIC activities. (Parent or Legal Guardian Signature) (Date)
Mail Page 2 and 3 to District Office NC YOUTH CAMP: THE OHANA EXPERIENCE CAMPER FORM AGES 11-17 LAST NAME FIRST NAME MIDDLE DATE OF BIRTH AGE GRADE GENDER: M or F MAILING ADDRESS CITY STATE ZIP PARENT/GUARDIAN NAME(S) PARENT/GUARDIAN HOME & CELL # INSURANCE INFORMATION HEALTH INSURANCE CARRIER INSURANCE COMPANY PHONE # POLICY NUMBER GROUP NUMBER ****Copy of Insurance card must be attached to camp application and mailed to district office with page 2 and 3.**** YOUTH SUMMER CAMP RULES 1. Guys and Girls are not allowed in each other s rooms. 2. No profanity. 3. No one is allowed to leave campus without permission from their Youth Leader and Camp Director. 4. NCYM reserves the right to search all personal belongings of campers and staff. 5. The following items are not allowed: -Weapons, firearms, knives, etc. -Articles of clothing that display questionable content -Drugs and Alcohol 6. Modest dress at all times: -No short shorts, spaghetti strap tank tops, crop tops, mini skirts or belly shirts -Shoes must be worn at all times -Modest swimwear is required. (No 2 piece bathing suites) 7. Any damage to property during camp will be billed to all parties/individuals involved. 8. Treat leaders and camp staff with respect at all times. I (we) have read the rules and agree to abide by them and do hereby give permission to participate in all camp activities. Signature of Parent/Guardian (Required) Signature of Camper (Required) 1 of 3
Mail Page 2 and 3 to District Office MEDICAL AUTHORIZATION AND HEALTH HISTORY (ORIGINAL FORM IS TO BE MAILED TO NCY OFFICE) STUDENT FULL NAME: STUDENT AGE: DOES THE STUDENT HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS? CONDITION YES NO 1 ASTHMA 2 DIABETES 3 SEIZURES 4 HEART CONDITION 5 ALLERGIES 6 BEE STING ALLERGY 7 FOOD ALLERGY 8 PEANUT FOOD ALLERGY PLEASE LIST ALL MEDICATIONS (PRESCRIPTION OR OTC) THIS CAMPER IS TAKING. 1. 2. 3. PLEASE LIST ANY AND ALL DISEASES, SERIOUS ILLNESS,INJURIES, OR SURGES THE STUDENT HAS OR HAS HAD: IS PERMISSION IS GIVEN FOR THE FOLLOWING OVER THE COUNTER MEDICATIONS TO BE GIVEN TO THE STUDEN AS NEEDED? (CHECK BOX) MEDICINE (OTC) YES NO ACETAMINOPHEN IBUPROFEN BENADRYL ANTIBIOTIC OINTMENT 2 of 3
Mail Page 2 and 3 to District Office EMERGENCY AND MEDICAL TREATMENT PERMISSION We, the parents and/or guardians of Participant, understand that we will be notified in the case of a medical emergency involving the Participant. However, in the event that we, or either of us, cannot be reached, we authorize the calling of a doctor, as well as 911, and the providing of necessary medical services in the event the Participant is injured or becomes ill. We authorize any one or more of the following persons to make emergency medical care decisions on behalf of the Participant, if required by law or a health care provider. I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered camper at any North Carolina Assembly of God summer camp, I hereby authorize any director, counselor, nurse, dean, lifeguard or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the United States, when such medical or surgical treatment is necessary. I also give to permission for my child to receive over-thecounter medication from their youth pastor and/or camp nurse if necessary. We agree to notify North Carolina Youth Ministries in the event of any health changes which would restrict the Participant s participation in any activities. We also understand that any North Carolina Ministries representative reserves the right to restrict the Participant from any activity for any reason. Parents/Guardian Signature: Date: Emergency Name and Phone Number: 3 of 3