2024 Camper Registration Form | Summit Camps Registration

Church Attending Camp With(Required)

Please select the name of the church you are attending camp with from the list below.

Church Camp Week(Required)

Please select the week you are attending camp from the list below.

Church Not Registered

Looks like your church is not registered yet! Contact your Children’s or Youth Pastor, Volunteer, or Leader and notify them that their church is not listed in the Summit Camps registration form.

Church Information

Do you normally attend a different church?(Required)

Yes

No

Regularly Attending Church Name(Required)

Camper Information

Camper's Name(Required)

First Last

Camper's Address(Required)

Street Address City State ZIP Code

Camper's Birth Date(Required)

Gender(Required)

Male

Female

Shirt Size(Required)

Camper Age(Required)

Please enter a number from 1 to 18.

Grade Fall 2024(Required)

Does Camper have a cell phone?(Required)

Yes

No

Camper's Phone(Required)

Guardian Information

Guardian Name(Required)

First Last

Guardian Address(Required)

Street Address City State ZIP Code

Guardian Email

Guardian Phone(Required)

Medical & Emergency Information

Primary Emergency Contact Name(Required)

First Last

Primary Emergency Contact Phone(Required)

Primary Emergency Relationship to Camper(Required)

Other Primary Emergency Relationship to Camper(Required)

Secondary Emergency Contact Name(Required)

First Last

Secondary Emergency Contact Phone(Required)

Secondary Emergency Relationship to Camper(Required)

Other Secondary Emergency Relationship to Camper(Required)

Has Camper been immunized for Tetanus?(Required)

Yes

No

Date of last Tetanus Immunization(Required)

Does Camper have a Primary Care Physician?(Required)

Yes

No

Camper's Physician Name(Required)

First Last

Camper's Physician Phone(Required)

Does Camper have any food allergies?(Required)

Yes

No

Please list food allergies below:(Required)

Will Camper be bringing any medication with them to camp?(Required)

Yes

No

Please list medications below:(Required)

CDIB Information

Does the Camper have a CDIB?(Required)

Yes

No

Tribal Nation(Required)

CDIB Number(Required)

Is the Camper Insured?(Required)

Yes

No

Health Insurance Information

Name of Insured(Required)

Name of the person who carries the insurance for the camper.

First Last

Address of Insured(Required)

Street Address Address Line 2 City State ZIP Code

Employer of Insured(Required)

Insurance Company(Required)

Insurance Company Phone(Required)

My Insurance Card has the following numbers(Required)

Policy Number

Group Number

Certificate Number

Policy Number(Required)

Group Number(Required)

Certificate Number(Required)

Mailing Address for Insurance Claims(Required)

Street Address Address Line 2 City State ZIP Code

Liability Release & Signatures

Does the Guardian of the Camper give permission for them to be given over-the-counter medication?(Required)

Yes

No

Does the Guardian need to be contacted before over-the-counter medication is given to their Camper.(Required)

Yes

No

Summit Camps Liability Release Agreement(Required)

I give permission for my camper to attend camp with and will not hold the attending Church, Summit Camps, Kiamichi Baptist Association, Green Country Camp (Green Country Baptist Assembly) responsible for any accident that may occur.

I also give permission for my child to receive medical treatment or attention in case of emergency or illness while traveling and/or while under the supervision of above referenced Church, sponsors, and/or camp staff.

I further give full authority to this Church’s staff & sponsors to discipline my child as may be deemed necessary. If my child’s behavior is such that it may endanger the happiness or the safety of the entire group, the sponsors have my permission to send my camper home after notifying me of their intention. I commit to pay the cost of the return trip should this action become necessary.

I expressly understand and acknowledge that during the course of the camp photographs and/or video footage of my child may be taken and I hereby give permission for such photographs or videos to be used on the camp website and/or for promotional materials for the camp.

I understand that it is the responsibility of my child’s Host church to obtain insurance

Iimit my child’s recreational activities because of a stated medical condition.

My child will be attending camp KBA or GCC. In the event that my child should need emergency medical care or attention, the Host Church leadership, KBA, GCC, Summit camps or any of their agents or employees Is hereby authorized to consent to the provision of such emergency medical care, including without limitation medical, dental, surgical care, or hospitalization, to my child as is recommended or suggested by a physician, nurse, surgeon, or other health care professional. If such emergency care is provided, I understand that my health Insurance Information will be given and KBA or GCC Insurance policy is to be secondary. I understand that the risk of injury from any recreational activity is significant, including, but not limited to the potential for permanent paralysis and death.

While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist. I knowingly and freely assume all risks, both known and unknown, even if arising from negligence, and assume full responsibility for my child’s participation in or observation of such recreational activity

• Furthermore, in consideration of my child being allowed to attend KBA or GCC, I, on behalf of myself and my child, hereby waive, and I hereby agree to indemnify and hold harmless the Host Church, KBA, GCC, Summit Camps Inc, their agents or employees, against any and all causes of action, rights, claims or suits which I or my child may have against the Host Church, KBA, GCC or their agents or employees as a result of injury to my child, including, but not limited to: (1) injuries arising from my child’s participation in or observation of recreational activities at KBA or GCC, and (2) injuries arising from the decision of the leadership of the Host Church, KBA, GCC, Summit Camps, or any of their agents or employees to consent to the provision of emergency medical care to my child.

•I have read, or had read to us the KBA/GCC guidelines, rules, and regulations and expect my child to abide by those guidelines.

Additional Activities:

I acknowledge that during the following additional activities are subject to certain risks and dangers that may occur. These include, but are not limited to, the hazards of depending on other people, being at various heights (ground to 45 feet), water hazards, hazards associated with archery, and the forces of nature. The undersigned further recognizes that these risks may also include physical or psychological damage and/or injury due to accidents which may occur resulting from the challenge course experience or other type of activities. While participating, the undersigned agrees to abide by all of the policies and procedures set before them in order to maintain the utmost level of safety.

In consideration of the above, the undersigned, do hereby assume all the above risks which are not foreseeable, and will hold KBA/GCC, its owners, directors, employees, and/or associates harmless from any and all liability, actions, causes of actions, claims, and demands of every kind and nature whatsoever, whether bodily injury, property damage or loss or otherwise, which may arise from, or in conjunction with, participation in this program. In short, I, along with my family or heirs, cannot sue KBA/GCC, Summit Camps Inc, its owners, directors, employees, and/or associates. Also agreed to that all participants is to not be under any influence of any chemical substance, whether legal or illegal, including alcohol. I fully understand that participation in these activities is strictly voluntary.

I agree to the Summit Camps liability release.