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2013 Children's Camp Application Camper's Full Name Address: Health / Medical Information Physician's Name: Phone # (_ )_ - Name of Insurance Carrier: Group Name / Number Policy Number Special Physical / Medical Needs: Medication taken regularly (Please list on separate piece of paper - send with child to camp. Please have meds labeled and in zip lock baggies with child's name, amount and times to be taken on the bag.) Allergies: Date of last Tetanus Shot / / Room mates (Please list who you would like to room with and add their church Name Church 1.) 2.) 3.) 4.) No changes will be made at camp!!  I hereby authorize medical treatment to the above named camper in the event of i llness or accident during the East Tennessee District Children's Camp, held Monday June 10 thru Friday, June 14,2013 "I hereby validate with my signature this registration form and do expressly waive any and all claims against the East Tennessee District Church of the Nazarene and / or its Board and / or any of its representatives, because of illness, injury, or damage t o the person or property of the above named camper in connection with or incident to East Tennessee District Children's Camp " Signature of Parent / Guardian Date: / / ALL REGISTRATIONS MUST BE NOTARIZED / / Notary's Signature Date Expiration Date of Commission / / Please include Shirt Size Circle one Children's sizes x-small small medium large Adult sizes small medium large x-large For Office Use Only Dorm: City State Zip Code Phone(_ )_ - Date of Birth / / Age: Grade Completed: S.S.# - -_ Male Female Name of Parent / Guardian Relationship to Camper_ Phone(_ )_ - Alt. # ( )_ - Address: City State Zip Code Church you attend Church # (_ )_ - Address: City State Zip Code Pastor Name 

Kids Camp Application 2013

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Page 1: Kids Camp Application 2013

7/28/2019 Kids Camp Application 2013

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2013 Children's Camp Application

Camper's Full Name 

Address:

Health / Medical Information 

Physician's Name:

Phone # (_ )_ -

Name of Insurance Carrier:

Group Name / Number 

Policy Number

Special Physical / Medical Needs:

Medication taken regularly (Please list on  separate piece of paper - send with child 

to camp. Please have meds labeled and in 

zip lock baggies with child's name, amount 

and times to be taken on the bag.)

Allergies:

Date of last Tetanus Shot

/ /

Room mates (Please list who you would like

to room with and add their church

Name Church

1.)

2.)

3.)

4.)

No changes will be made at camp!! 

I hereby authorize medical treatment to the above

named camper in the event of i llness or accident

during the East Tennessee District Children's

Camp, held Monday June 10 thru Friday, June 14,2013

"I hereby validate with my signature this registration

form and do expressly waive any and all claims against

the East Tennessee District Church of the Nazarene

and / or its Board and / or any of its representatives,

because of illness, injury, or damage t o the person or

property of the above named camper in connection with

or incident to East Tennessee District Children's Camp "

Signature of Parent / Guardian 

Date: / /

ALL REGISTRATIONS

MUST BE NOTARIZED 

/ /

Notary's Signature Date

Expiration Date of Commission / /

Please include Shirt Size Circle one Children's sizes 

x-small small medium large

Adult sizes 

small medium large x-large

For Office Use Only

Dorm:

CityState Zip Code

Phone(_ )_ -

Date of Birth / / Age:

Grade Completed:

S.S.# - -_ 

Male Female

Name of Parent / Guardian 

Relationship to Camper_ 

Phone(_ )_ -

Alt. # ( )_ -

Address:

City

State Zip Code

Church you attend

Church # (_ )_ -

Address:

City 

State  Zip Code 

Pastor Name 

Page 2: Kids Camp Application 2013

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2013 Children's Camp Application

Camp Cost $150.00

1st

grade-6th

grade

Send Application to: Coordinator Contacts:

John & Melinda Hale Melinda : 423-765-7569 [email protected] 

1402 Sevier Terrace Drive John: 423-429-8420 [email protected]  

Kingsport, Tn. 37660 Melissa Wilson: 931-224-6139 [email protected] 

Must be postmarked by:

May 13th

 or $20.00 late fee will apply

Make Checks payable to: ETN Dist SDMI

Camp Guidelines

1.  No fireworks, firearms, paint ball

guns, spray paint, knives,

tobacco, drugs or alcohol.

Violators will be sent home.

2.  No electronic equipment

allowed. These devices distract

campers.

3.  Mattresses should be covered

with a sheet even if a sleeping

bag is used.

4.  Campers and Counselors are

asked to dress modestly & shoes

must be worn at ALL times.

Unacceptable Items include:

short shorts, low cut tops & two

piece swim suits that do not

cover abdomen.

5.  Please do not send good clothing

that may be ruined or left

behind and place name and

church on all items.

Telephone & Security1.  A camp telephone is available for

emergencies only. Any cell phone

brought to camp is theresponsibility of the camper and is

not to be used during camp

activities.

2.  Parents/guardians may call or text

the camp coordinators at any time.

3.  All rooms and personal items are

subject to be searched.

4.  All visitors must notify the camp

directors upon entering camp

property.5.  All campers must be in dorms and

accounted for at lights out.

6.  No camper is to be outside the

dorm for any reason after this time.

7.  Do not send money with child.

A pastor and/or parent will be contacted if a

child is in violation of Camp rules and the

child will be sent home at the expense &

inconvenience of the parents.

Packing List

1.  Bible

2.  Soap, shampoo, toothbrush,

toothpaste, and hygiene items.

3.  Towels & washcloths

4.  Sleeping bag, sheet, pillow &

blanket.

5.  Clothes…including socks, shoes

and swimsuit.

6.  Last but not least….A Great &

Positive Attitude!!

Camp RegistrationLocated in the conference center below

the hotel.

Monday 1pm-4pm (EST)

No Early Registrations/No Exceptions. 

Departure

Noon dismissal from Tabernacle.

Please copy this form for at home use

while your child is at camp.