1. automotive and vehicles
2. campers and rvs

Kids Camp Information Dates: July 6-­‐10 Ages: 8 to 12 years old. No exceptions. Children must be 8 by the start of camp. Cost: Total Registration Cost=$225. A non-­‐refundable deposit of $100 is due by MARCH 22. The remaining balance is due by May 17. Family Discount: $25 discount for each additional camper from the same immediate family. Registration Deadline: A $100 deposit and completed registration forms are due by MARCH 22. No exceptions. Location: Pine Creek Camp in Gore, Virginia. The camp is equipped with rooms that house 5 campers and a chaperone. Each room contains its own bathroom. Camp Speaker: Dick Gruber Activities: Swimming, Zip lines, Rock Climbing Wall, Inflatables, Paddle Boats, Clubs, and much more Money Cards: Any purchases made by campers must be made with a camp money card. Cards may be pre-­‐ordered on your registration form or you may turn in money on the day camp starts. More Info: If you would like more information and the opportunity to ask questions, please attend an Informational Meeting on Sunday, March 15 after 2nd Service L103. Information about what to bring to camp will be given out one month before camp. Kids Camp Parent Agreement: q I understand the $100 deposit is not refundable. q I understand that my remaining balance for Kids Camp is due on May 17 and my child’s place at camp will be forfeited if the payment is not made. q If this is the first time my child has attended Kids Camp with Cornerstone Church, I understand that I am required to attend a Parent Meeting. q I understand that all medication must be turned in before Kids Camp. q I understand that if I don’t pay for a money card now, I will need to turn in money on the day we leave for camp. _____________________________________________________________________________________ Parent’s Signature Date Do NOT
use
staples
Duplicate forms as needed; PLEASE DO NOT make back-to-back copies of camper registration and medical form
Potomac District Kids Camp 2015
First Name
Sex
M
F
Mailing Address
City
Camper Registration
PERSONAL INFORMATION
Last Name
Birthdate (MM/DD/YYYY)
Age by opening day of camp:
ST
Zip Code
Name of church you are registering with:
City and state where church is located:
Both the camper registration and medical form must include emergency contact information.
In case of emergency, contact:
Contact’s relationship to student: Mother Father
Contact’s phone number (area code + number)
Additional phone numbers:
Grandparent
Guardian
Other:
ACTIVITY CLUBS
Ask your camp coordinator for a list of club descriptions. Put a 1, 2, and 3 in front of your TOP THREE choices. ((If you do
not mark your three top preferences, clubs will be randomly chosen for you.)
CC Clay Creations
GC Girls Club
LE Legos
PD Pinewood Derby
SP Sports
CO Cooking
GE Geocaching
MU Music Creations
PH Photography
DR Drama
HV Human Video
NE Nature Exploration
RO Rockets
FREE CAMP T-SHIRT INCLUDED WITH REGISTRATION: PLEASE CHOOSE YOUR SIZE
YM (Child 10-12)
YL (Child 14-16) S M L XL XXL XXXL
If no size is selected, one will be randomly selected for you.
TOTAL DUE
Qty:
Souvenir Camp DVD: $15
Qty:
Souvenir All-Camp Photo: $10
Pre-ordered Camp Money Cards: Fill in the total money amount you want to pre-order. All camp
purchases must be made with a camp money card. Money cards may also be purchased upon arrival.
Registration Cost:
Multiple Family Discount: $25 discount for each additional camper in your immediate family
TOTAL AMOUNT DUE: Make check payable to your church.
-
STUDENT’S SIGNATURE OF COMPLIANCE
I have read, and agree to abide by, the camp policies and guidelines, including the dress code. I
understand that willful misconduct or any breach of the policies and guidelines will cause my dismissal from
camp, at any time, day or night, at my parent or guardian’s expense.
STUDENT’S SIGNATURE (Required):
Registration cannot be accepted without valid signature of student
Please submit to your children’s pastor or Kids Camp coordinator this (1) camper registration, along
with (2) a medical form, (3) a copy of your insurance and/or prescription card (if you are insured),
and (4) a check made payable to your church.
Potomac District Kids Camp 2015
Camper Registration
Do NOT
use
staples
Duplicate forms as needed; PLEASE DO NOT make back-to-back copies of camper registration and medical form
Potomac District Kids Camp 2015
PERSONAL INFORMATION
Student’s First Name
Last Name
Church Name:
Church City/State:
Sex
M
F
Birthdate (MM/DD/YYYY)
Age:
Medical Form
Weight:
Both the camper registration and medical form must include emergency contact information.
In case of emergency, contact:
Contact’s relationship to student:
Mother Father Grandparent Guardian Other:
Contact’s phone number (area code + number)
Additional phone numbers:
INSURANCE INFORMATION
Is the above named student insured?
NO, I have no insurance.
YES, the name of my INSURANCE COMPANY is:
A copy of my insurance and/or prescription card is attached. MANDATORY FOR ALL INSURED STUDENTS: On an 8 ½ X
11 piece of paper, please copy the front and back of your insurance and/or prescription card, and paperclip (do not staple) to this
medical form. In case of a medical emergency, this information is vital in securing timely medical treatment for your child.
TRICARE INSURANCE: For students from military families who use Tricare that provides no card beyond the sponsors ID card,
the nursing staff has informed us that the following will be required:
•
Sponsor’s Name (usually the parent):
•
Sponsor’s Social Security Number:
NOTE: All sensitive information, including social security number, will be carefully protected.
DOCTOR’S NAME AND CONTACT INFORMATION
Student’s primary or family doctor:
Doctor’s address:
City/State:
Doctor’s phone number (area code plus number)
MEDICAL HISTORY: Attach a detailed note of explanation if necessary
Has student had all current immunizations as regulated by your state?
Has student recently been exposed to a communicable disease? If yes, explain on separate sheet.
Does student have physical needs that would limit participation in camp activities? If yes, explain on
separate sheet.
Student will be bringing inhaler nebulizer epi-pen The epi-pen is for:
Student has the following allergies:
Student is allergic to the following medications:
Is there any information that we should have regarding the welfare of this student? Please be sure to include recent
illnesses, handicaps, special diet, etc.
YES
YES
YES
NO
NO
NO
For monitored pool events, I request that my student be given a special ID bracelet to identify him/her as a non- or weak swimmer.
MEDICATIONS
List ALL medications student will be bringing to use at this event. Medications, prescriptions and over-thecounter drugs CANNOT be given to a student unless they are in the ORIGINAL container!!!
EMERGENCY TREATMENT PERMISSION & LIABILITY RELEASE
I give permission for my child to attend this event and participate in its activities. While my child is at this event, I give permission for the administration of the above
medications and other comfort medications including, but not limited to Tylenol, Advil, cough drops and Mylanta. Furthermore, whereas I have legal custody of this child, a
minor who resides with me, I give the following emergency treatment permission: While this child is at, or in route to and from, this event, I hereby authorize any first aid
staff, kids camp staff or designated church chaperone to consent to any X-ray, examination, anesthetic, medical or surgical treatment, and hospital care to be rendered to
this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state of WV,MD or VA when such medical or
surgical treatment is necessary. I understand that the term chaperone or counselor refers to "a person in charge of a group of children” and does not imply the individual is
licensed to give counsel. In consideration of my child being allowed to participate in this event, I authorize the Potomac District Council of the Assemblies of God to use
my child's likeness in photographs or video in any and all of its publications and in any and all other media. I will make no monetary or other claim against the District for
the use of such photographs or video. I hold harmless and release the Potomac District Council of the Assemblies of God, and its agents and employees from any liability,
claims, damages and loss whatsoever relating to the authorizations hereinabove provided for.
SIGNATURE OF PARENT/GUARDIAN (Required):
Med form cannot be accepted without valid signature of parent or guardian
Potomac District Kids Camp 2015
Medical Form
GIRLS CLUB (GC) is a club that emphasizes friendship and the
uniqueness of girls. You will discover what the Bible says about
GEOCACHING (GE) In the Geocaching (pronounced GEE-O-CASHING) Club you will use a GPS device to hunt treasures hidden among
the trails and grounds of the camp. While solving clues and searching
for these treasures or “caches” you will be exploring God’s creation.
You are encouraged to bring your camera (optional), good walking
shoes and an explorer’s attitude. Leaders should come prepared to
direct campers in using a GPS tracking device. Good hiking or
walking shoes and extra bug spray are recommended.
DRAMA (DR) In Drama Club you will work with other campers to
create a 5-minute drama skit. You should be able to memorize your
part of the drama script with expression and emotion. The drama will
be presented on the final day of camp. Leaders should come
prepared with several different scripts. The skit should be selected on
the 1st club day, practiced and perfected on the remaining club day(s)
and will be presented during the final chapel service. Supplies:
Leaders will bring any desired costumes or props.
COOKING (CO) In Cooking Club you will have the opportunity to
learn skills that will help you become a better cook/baker such as
following recipes, measuring and utilizing cooking utensils and
appliances. After you have prepared each recipe you will be able to
taste the final creation. Leaders will direct campers in preparing a
different recipe for each club day in one of the staff house kitchens.
Selected recipes should be chosen to fit within the allotted club time.
The kitchen/dining/living room area is the only area of the house that
is available to campers; leaders should encourage campers to clean
up their area at the end of club time. Supplies: A fully functioning
kitchen is available—stove, fridge, microwave & cook top, as well as
various kitchen utensils and pots/pans. The leader may purchase
and/or bring utensils and supplies to camp. Budget: $50—receipts
should be saved and turned in for reimbursement.
CLAY CREATIONS (CC) In Clay Creations you will be encouraged to
use your imagination in creating artwork that expresses your
personality and interests. You will make several pieces and have the
opportunity to paint each after drying. Completed projects may be
taken home to show your family and friends. Leaders should come
prepared to help campers think about creative expression, emphasize
rapport among campers and help in the use of the clay and tools.
Campers will wear smocks and table covers will be used. Leaders
should encourage campers to clean up their area at the end of club
time. Supplies: Provided supplies include clay, molds, smocks,
paint, brushes, table cover, and clay tools.
NATURE EXPLORATION (NE) In the Nature Exploration Club you will
explore God’s creation up close as you hike various trails throughout the
camp. Good walking shoes and a positive attitude are required. You are
encouraged to bring your camera (optional) as you enjoy the beauty of
nature. Leaders should come prepared with scripture references and
devotions, be physically prepared to walk and hike and be
knowledgeable about different types of trees, bugs and other natural
landscape to show to campers. Various trails are available to use.
Good hiking or walking shoes and extra bug spray are recommended.
MUSIC CREATIONS (MC) Campers will learn a song and/or musical
percussion number by combining vocals with instruments made from
every day objects—water bottle full of rocks, sticks beating on pails, etc.
The music creation will be presented on the final day of camp. Leaders
should come prepared with several song ideas and objects that may be
used to create that song. Supplies: Minimal to none.
LEGOS® (LE) In the Lego® Club you will use your imagination,
creativity and building skills individually, and as a group, to create a daily
Lego® work of art that will be photographed each day for display at the
end of the week. Leaders should come prepared with ideas for
individual Lego® projects and/or for a corporate project for the campers
to build. Suggested club limit: 12 campers. Supplies: Provided
supplies include thousands of basic Lego® pieces in all shapes and sizes
and a camera for capturing each day’s creation(s).
HUMAN VIDEO (HV) In the Human Video Club, the group will work
together to develop a dramatic presentation to music. You will learn to
show with dramatic movement a story that is being told by the music.
There are no lines to be memorized but you should be able to show
expression and emotion. The human video will be presented on the final
day of camp. Leaders should come prepared with a CD of music and
lyrics and be prepared to teach the dramatic movements and
presentation that will accompany the music. No costumes are required
and the only props allowed are chairs. The human video should be
selected on the 1st club day, practiced and perfected on the remaining
club day(s) and will be presented during the final chapel service.
Supplies: Minimal to none.
beauty and learn respect for yourself and others as you are taught to
value your inner beauty. In this club you will also learn how to enhance
your natural features and loveliness. Leaders should come prepared
with lessons for each day. Prov 31 and Ps 139:14 are recommended
scriptures. Suggested activities include: manicures, pedicures, facials,
hair styling and beading/jewelry making. Supplies: Leaders will
purchase and bring all necessary supplies. Budget: $50—receipts
should be saved and turned in for reimbursement.
SPORTS (SP) is an active club in which you will use various sports
equipment to have fun and improve your physical skills, work together as
a team and become a better athlete. Leaders will be expected to
research and teach/explain the sport to approximately 15-20 campers
prior to their participation. This club requires a leader and at least two
helpers. Due to the campers’ age diversity, it is recommended that
campers be divided first into an older and younger group and then from
there divided into teams. This will allow all ages to participate on a level
with their peers. Supplies: Available sports equipment includes
basketball, football with flags, soccer with goals, & dodge ball.
ROCKETS (RO) In Rockets Club you will learn how to build a rocket from
start to finish. After the rocket has been built you will paint, decorate and
launch it. Unless it is lost in launch, you will be able to take your rocket
home to show family and friends. Leaders should come prepared to
direct campers in building their individual rocket using rocket kits supplied
by the camp. Patience will be required as fine motor skills are needed.
Because some campers will be better suited to use their motor skills than
others, extra encouragement may be required for some. First-time
leaders may request a rocket kit be mailed to them so they can practice
assembly and know what will be expected. Supplies: Supplies provided
include rocket kits, launching supplies and spray paint.
PINEWOOD DERBY (PD) In the Pinewood Derby Club you will learn how
to build a Pinewood Derby car from start to finish. After the car has been
built you will paint, decorate and race it. You will be able to take your car
home to show family and friends. Leaders should come prepared to
direct campers in building their individual car using car kits supplied by
the camp. Patience will be required as fine motor skills are needed.
Because some campers will be better suited to use their motor skills than
others, extra encouragement may be required for some. First-time leaders
may request a car kit be mailed to them so they can practice assembly
and know what will be expected. Supplies: Provided supplies include
cars kits, tools, and spray paint.
Photography (PH) In the Photography club you will use a digital camera
to take pictures of nature and the scenic views on camp. You will have 3
pictures of your choice developed and make a frame for your favorite
photo. You are encouraged to bring your camera (optional), and good
walking shoes. Suggested club limit: 10 campers. Leaders should come
prepared to walk, have a working knowledge of the various functions of a
standard digital camera and assist campers in enhancing their
photography skills. Supplies: Provided supplies include a digital
camera, SD card, picture frames.
Supplies: Minimal to none.
Kids Camp offers 13 different activity clubs. Each club will meet for three days (Tues, Wed & Thu) for about 1 hour and 15 minutes. Approximately 15 campers and 1-3 chaperone leaders/
helpers will be assigned to each club. The following descriptions will give you an idea of what activities to expect from each club. On your registration form, you will mark your three top club
preferences. Every effort will be made to assign you to one of your three choices.
KIDS CAMP 2015 CLUB DESCRIPTIONS
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