"*" indicates required fields

I will be attending as a camper*
Name*
Date of Birth*
Address*
Gender*
Saved?*
Sanctified?*
Holy Ghost?*
Member of The Church of God*
T-Shirts - $20*
T-Shirts have to be paid for in advance.
Do you hold any positions as a church leader?*
If camper is under 5 parent may sign.
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.*
Name of Parent/Guardian*
Name of person authorized to pick up camper*

Health Information

Name*
Please Check all that apply.*
Please give approximate dates of occurrence in the box below.
Allergic Reactions*
Please give more detail of what you are allergic to and your allergic reactions in the box below.
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.
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 Information

Name of Insured*
Date*
Emergency Contact*
Permission to use Photograph for The Church of God, NC - Family Camp
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*
FAMILY PLAN (Cost reflects ages 6 and up) (family must live in same household) Choose the plan of the number in the household that is age 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) *Deduct $5 from plan for each member of staff. APPLICATION DEADLINE May 1, 2023 No applications after deadline unless extenuating circumstances occur.
Payment Options*
A deposit of $20.00 is required with this application for coverage of insurance while in-route to camp. T-Shirts must also be paid in advance to get one. You may cancel up to 1 week in advance and receive a refund. There are no refunds for T-Shirts.