...take hold of that for which Christ Jesus took hold of me.

- Philippians 3:12b

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Student’s First & Last Name Birth Date

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Parent(s)/Guardian First & Last Name

______________________________________________________________________________________________

Address City State Zip Code

______________________________________________________________________________________________

Home Phone Cell Phone Parent Email

______________________________________________________________________________________________

School Campus Grade

Medical Information

______________________________________________________________________________________________

Student’s Medical Insurance Provider Insurance Policy Number

______________________________________________________________________________________________

Physician’s Name Phone Number

______________________________________________________________________________________________

Allergies and/or medical condition we should be aware of:

Please circle T-Shirt size below:

Women’s: XS S M L XL

Men’s: XS S M L XL

Are you interested in scholarship / fundraising? ( ) Yes ( ) No

For office use only:

________________________________ _________ ___________________________

Date Paid Amount Received by

Payment type: ( ) Cash ( ) Check ( ) Scholarship/Fundraising

Grace Bible Honolulu Church Office: 1136 12th Avenue, Suite 230, Honolulu, HI 96816 Phone: 808.531.4224

RRREGISTRATIONEGISTRATIONEGISTRATION IIINFORMATIONNFORMATIONNFORMATION

Grace Bible Honolulu Church Office: 1136 12th Avenue, Suite 230, Honolulu, HI 96816 Phone: 808.531.4224

Parents Please Read and Sign Below:

We further grant permission for our child/minor to travel by Church or private vehicle to and

from the above destination.

Release of all Claims and Indemnification

1. In consideration of permission grant to ____________________ (print minor’s full name) herein-

after the “participant” by Grace Bible Honolulu to participate in the activity listed above,

the undersigned hereby releases, discharges, and covenants not to sue Grace Bible Hono-

lulu, Every Nation Ministries, it’s agents, employee’s and officers from all actions, causes of

action, damages, claims, or demands which the undersigned and or participant ever had,

or now has, or may have, or which the undersigned and/or participant’s heir, executors,

administrators, or assigns may have, or claim to have against Grace Bible Honolulu, it’s

agents, employees, and officers for all personal injuries and property damage, known or

unknown, which the undersigned and/or participant have or may incur by participating in

the above described activity.

2. As additional consideration for permission to participate in the above-described activity the

undersigned agrees to indemnify, save, and hold harmless the Church, it’s agents, employ-

ees, and officers from any and all deaths, injuries, losses and damages to persons or prop-

erty, and any and all claims, demands, suits, actions and liability therefore, caused by the

participant’s participation in the above activity.

3. The undersigned agrees to authorize such medical treatment as necessary in the event of

illness or injury to said participant.

4. If applicable, the undersigned as a parent(s) or legal guardian(s) of the participant repre-

sents to Grace Bible Honolulu, that facts herein concerning the participant are true. The

undersigned hereby gives you permission for the participant to participate in the above

described activity, and further, in consideration of permission granted by Grace Bible Hono-

lulu to participate in the above-described activity. Agree individually and on behalf of the

participant to the terms of the above Release of all Claims and Indemnification.

5. The undersigned has received and read the informed Consent and Assumption of the Risk

for the activity listed on the previous page and knows the contents thereof.

______________________________________________________________________________________________________

Agreement of parent(s)/legal guardian(s)

We hereby give our child __________________________ (print full name) permission to attend the following

excursion/event conducted, sponsored, or attended by Grace Bible Honolulu.

_______________________________________ ______________

Parent / Legal Guardian Signature Parent / Legal Guardian Print Name

_________________________________________

Date

Transportation Provided by: Ground Transport

Departure: Church Office (1136 12th Ave, Suite 230)

Saturday, July 12th at 1:00 pm

Return/Pick-up: Church office

Monday, July 14th at 1:00pm

What: Youth Camp

Where: Camp Pu’u Kahea

85-199 Ala Hema Street

Waianae, HI 96792

When: July 12-14, 2014

Contact Number:

Blaine Santa Monica (Youth Director) 808.531.4224

Camper Expectation Students please read and sign bottom

Campers are expected to follow the following ten (10) rules at all times.

1. Follow instructions the first time given.

2. Don’t cause the person next to you to lose eye contact with speaker

during sessions & announcements.

3. Always keep hands and feet to yourself. No rough housing or horseplay.

4. Always tell your adult leader where you are going.

5. Always wear a T-shirt and footwear.

6. Always wear deodorant daily.

7. Ask permission to enter any activity area or non-cabin areas.

8. Trash goes in the garbage cans.

9. Listen to each other and cooperate.

10. Always participate, have FUN and have an open HEART to hear what

God has for you!

Meals are eaten family style seated in the dining hall. Campers are expected

to attend all meals and observe appropriate table manners. Campers will

help clean the dining hall after a meal on a rotating basis.

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Student Print Name Student Signature Date

Basics No-no’s

_____Bible No ipods, radios, other electronics

_____Journal/Notepad No alcohol, illegal drugs, & cigarettes

_____Pen/Pencil No skateboards, footballs, sporting goods

_____Medication (if applicable) Any illegal items will be confiscated!!!

_____Shoes/Slippers/Socks

_____Towels - at least 2 (1 for bath, 1 for games)

_____Insect Repellent (optional)

_____Sunscreen

_____Water Bottle (optional)

_____Non-perishable snacks (meals & some snacks will also be provided)

_____Personal Bedding (sheets, pillows, sleeping bag/blanket)

Toiletries Clothes

_____Soap _____Comfortable clothes

_____Shampoo & Conditioner _____Warm clothing (may get cold at night)

_____Deodorant _____Set of “junk” clothes that may get dirty

_____Toothbrush / Toothpaste / Floss _____Swimwear (modest)

_____Hairbrush / Comb _____Undergarments

_____Other personal hygiene items

What To Bring

What: Youth Camp

Where: Camp Pu’u Kahea

85-199 Ala Hema Street

Waianae, HI 96792

When: July 12-14, 2014

Cost: $125 - Registration for first child

$75 - Discounted price for additional siblings

- Registration must be received by June 15, 2014 to guarantee shirt size

- Last day to register and pay for camp is Sunday, July 6, 2014

- Registration cost covers room & board, meals, t-shirt, & transportation.

Transportation Provided by: Ground Transport

Departure: Church Office (1136 12th Avenue, Suite 230) - Saturday, July 12th at 1:00 pm

Return/Pick-up: Church Office - Monday, July 14th 1:00 pm

Contact Numbers: Blaine Santa Monica (Youth Director) 808.531.4224

Grace Bible Honolulu Church Office: 113612th Avenue, Suite 230, Honolulu, HI 96816 Phone: 808.531.4224

Parent’s Info...

Parents please keep this page for your records