Teen Retreat 2023 Registration

Camper's Full Name *

First, Middle, and Last

Gender *

Male
Female

Birthdate *

Age (while at camp) *

Grade *

Mailing Address *

City *

State *

Zip Code *

Parent/Guardian's Name *

First

Last

Parent's E-mail Address

Do you regularly attend a church?

If yes, which one?

Cabin Mate Request

________________________________________________________

Retreat Fees

Fees due with Registration, unless prior arrangements are made with the camp director.

Retreat Fee Online Payment (will be processed through Paypal)

Retreat Fee - $ 75.00

We will be offering Airsoft as an optional activity at this retreat. There will be an extra fee of $10 for this activity.

_______________________________________________________

Camper Release (Photo ID Required for pick up)

Please list Parents/Guardians and emergency contacts. In the event of an emergency, we will contact adults in the order listed below. This will also act as a list of those people authorized to pick up your child from camp.

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Name

Relationship

Phone Number

_______________________________________________________

Medical Information

Any known health or behavioral concerns?

Other Information (anything else you would like us to know about your child’s behavior or physical, emotional, or mental health including activity restrictions.):

Any Drug Allergies?

Food Allergies/ Restrictions? (If food modifications are significant, please contact us to make prior arrangements. You may be asked to provide easy-to-prepare substitutions.)

Other Allergies?

Insurance Company

Policy Number

Primary Care Physician

Phone Number

(Our insurance will not cover any pre-existing conditions. In case of accident or injury, your insurance will be considered primary. Camp Ozone insurance will be submitted as secondary.)

________________________________________________________

Bring Medication and completed Medication form (from confirmation packet) in a gallon-sized storage bag to check-in. You must bring current medication in its container with instructions.

________________________________________________________

Release and Waivers

Release and Waiver: The information given above is correct and complete as far as I know. I understand that there are risks of physical injury involved in camp activities, and I agree to accept the full risk as a part of my child’s participation. I further agree to indemnify, hold harmless, and defend Camp Ozone, its board members, executive officers, staff, and employees from any and all claims for injuries, damages, or loss sustained by me or my child arising out of, connected with, or in any way associated with Camp Ozone.

Emergency Authorization: I hereby give permission to the first aid personnel selected by the camp director to provide standard first aid care, administer over-the-counter medication, seek emergency medical treatment, and arrange related necessary transportation. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp personnel to order x-rays, routine tests, hospitalize, secure proper treatment for and to order injection and/or surgery for my child as named above. I agree to the release of medical records necessary for treatment, referral, billing, or insurance purposes.

Promotional Release: I hereby give permission for the use of photos/videos in which my child may appear to be used for any promotional materials.

By making application: - I agree to have all my child’s medication turned in to the camp nurse at registration. - I give my child permission to participate in the entire camp program unless otherwise noted. - I understand that if my child misbehaves or brings unacceptable items he/she will be sent home without a refund. - I assure that my child will not bring a cell phone and will abide by the dress code sent with the confirmation.

I have read and agree to all of the Waivers and Releases listed above.

I would like to receive Camp Ozone e-mail newsletters and updates