"*" indicates required fields Name* First Last Age as of June 1*Grade Entering in the FallDate of Birth*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender* Male Female Phone*Saved?* Yes No Sanctified?* Yes No Holy Ghost?* Yes No Member of The Church of God* Yes No Local Church*Do you hold any positions as a church leader?* Yes No If yes, please list positions currently held.Camp T-Shirt - $25.00 Small Medium Large X-Large 2X-Large 3X-Large 4X-Large No T-Shirt T-Shirts have to be paid in advance.Consent* I agree to the rules below.Rules for acceptance & participation of camp are the same for each person without regard to race, gender or national origin. Please do not bring electronics. Camp will not be responsible for lost or damaged electronics. There will be no pillow fighting, water guns or water balloons used inside a building. No shaving cream fighting or playing, illegal drugs, tobacco products, alcohol, fireworks of any kind or weapons of any kind. I understand that when signing this application, I am agreeing to abide by all rules and regulations of the camp. If I break any rule, I understand that I am subject to disciplinary correction even to the expelling from camp. The Church of God Family Camp Dress Code: To Parents and Campers. This is a Christian Camp. Please dress accordingly. Boys should wear long pants, girls' hemline BELOW the knee (hemlines need to be below the knee while sitting). The following clothes ARE NOT ACCEPTABLE: shorts, leggings/jeggings, tank tops, sheer fabrics, sleeveless tops, no cut-offs, no bare stomach or back showing, no low-cut tops, no shirts with profane words and/or pictures. To all church services - girls should wear dresses or skirts, boys should wear jeans or slacks. If girls choose to wear leggings under their dresses/skirts, the hemline of the skirt still must be below the knee while sitting. PLEASE MARK ALL PERSONAL ITEMS WITH CAMPER'S NAME. Camping staff WILL NOT BE RESPONSIBLE for missing clothing or items left on campground.Signature of Parent/GuardianSignature of CamperList Activities you DO NOT want your child to participate in.*Recreation Activities consist of: Rock Wall, Blob, Zip Line, Large Swing, & Archery. If you prefer for your child to NOT Participate in any of these activities, please list the specific activities above. If they can participate in all of them put N/A.I give permission for the above-named minor to be baptized in water during camp if they desire.* Yes No Name of Parent/Guardian* First Last Parent/Guardian Phone*Parent/Guardian Email* Camper Email* Camper Phone*Name of person authorized to pick up camper* First Last Name of second person authorized to pick up camper First Last Enter the First and Last name of a second person authorized to pick up your camper if available. Health InformationName* First Last Please Check all that apply.* Rheumatic Fever Seizures Fainting Asthma/Respiratory Tuberculosis Diabetes Kidney Problems Heart Trouble Sleep Walking Poison Ivy, Oak, Sumac Recent Surgery None Please give approximate dates of occurrence in the box below.Allergic Reactions* Bee Stings Drugs Food(S) None Please give more detail of what you are allergic to and your allergic reactions in the box below.Additional Health concerns, allergies, and/or limitations.*If you checked any of the boxes other than NONE in the previous two question please give details here. You may also add any additional details of heath concerns in this box.Please list any prescribed medications.*All medication is to be given to the camp nurse to administer to the camper unless approved by camp administration. Put N/A if you are not taking any medications.Insurance InformationName of Insured* First Last Insurance Company*Group Number*Policy Number*Medical Consent by Camper (or by Parent/Guardian if under 18)* I agree to the medical consent below.All medication is to be given to the camp nurse to administer to the camper unless approved by camp administration.Medical Expense Liability (or by Parent/Guardian if under 18)* I agree to the Medical Expense Consent below.I understand that if any accident or sickness should occur, which the camp insurance does not provide, the expense is my own responsibility and the camp will not be held liable for any expenses. SignatureDate*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Emergency Contact* First Last Phone*Relationship*Permission to use Photograph for The Church of God, NC - Family Camp Yes No I grant to The Church of God, it's representatives the right to take photographs of me (or my child) and my property in connection with the above-identified subject. I authorize The Church of God, it's assigns and transferees to copyright, use, and publish the same in print and/or electronically.Camp Tuition* 1 Person - $115.00 Early Bird $95.00 2 People - $220.00 Early Bird $180.00 3 People - $325.00 Early Bird $265.00 4 People - $430.00 Early Bird $350.00 5 People - $535.00 Early Bird $435.00 6 People - $640.00 Early Bird $520.00 CAMPER FAMILY PLAN (Cost reflects ages 6 and up) (family must live in same household) Choose the plan that matches number of campers in the household ages 6 & up. For ages of 3-5, you will add $20 to family plan to cover food cost. Ages 2 & under - no cost. The SNACK SHACK will be open to purchase snacks/drinks. This is NOT included in the tuition. Snack Shack cards can be purchased in advance or at camp. ($5 per card) EARLY BIRD DISCOUNT Applications submitted before the May 1, 2026 deadline will receive a $20 early bird discount for each camper.Name for other members in your family plan.Payment Options* Today (Online) In Person (At Checkin) A deposit of $20.00 is required with this application for coverage of insurance while in-route to camp. You may cancel up to 1 week in advance and receive a refund.
