...take hold of that for which Christ Jesus took hold of me.
- Philippians 3:12b
___________________________________________________________________
Student’s First & Last Name Birth Date
______________________________________________________________________________________________
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.
__________________________________________________________________
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