MS District UPCI Junior Youth Camp 2024

Registration Options

Girl Dorm Camper ($150.00) [Join Waitlist]
Registration for a female camper that will stay in the dorm for the week.
Boy Dorm Camper ($150.00) [32 remaining]
Registration for a male camper that will stay in the dorm for the week.
Girl Day Camper ($150.00)
Registration for a female camper that will not be staying in the dorms.
Boy Day Camper ($150.00)
Registration for a male camper that will not be staying in the dorms.

Parent/Guardian Contact Email Address

Parent/Guardian Contact Phone Number

The following information is for the attendee, not the person filling out the form (unless it is the same person). You will have the opportunity to register multiple attendees on the next page(s) if desired.

Name

Nickname (if any)

Address

Gender

Male
Female

Date of Birth

Campers must be between the ages of 7-12 at the time of camp!

Parent/Guardian Name

Is anyone else besides the listed Parent or Guardian allowed to check out or pick up this camper?

Pastor's Name

Pastor's Email Address

Name of Church

Church City

Any allergies, illnesses, or other diseases?

If Yes, please explain

Is this person diabetic?

If Yes, what is the daily insulin intake?

Does this person take any medication?

If Yes, please explain

Does this person wear contact lenses or glasses?

Yes, contact lenses
Yes, glasses
Yes, both
No

Does this person wear a hearing aid?

Has this person had a tetanus shot in the last 12 months?

Has this person been affirmed to be free of head lice?

Does this person have Medical Insurance Coverage?

If Yes, list company and policy number

Is this person currently under a doctor's care?

If Yes, please list doctor's name, phone number and treatment

Please list any other health issues or important information

Has this child received the Holy Ghost?

Yes
No
Not sure

Please acknowledge that you have read and consent to the following statements:

Photography and Videography

I understand and consent to the following photography and videography statement
Services will be livestreamed and photographers and videographers will be on site. Campers may be photographed and or videoed and potentially appear in the livestream and other future Children's Ministry and Camp promotional materials.

Medical Consent

I understand and consent to the following medical consent
The undersigned participant and his/her parent/legal guardian agree to hold MS District UPCI, it's employees, officers, and volunteers from any claims, damages, losses, and /or expenses arising out of participation in camp activities and to assume all liability for any and all personal injury, bodily injury, illness or property damage that occurs as a result of participation in such activities.

Acknowledgement of this agreement also warrants that
participation in this camp is voluntary and that the participant and undersigned understand the inherent risks involved in the camp's activities. The participant understands that these risks exist despite the camp's safety precautions and procedures and the participant agrees to obey all rules and policies mandated by camp personnel.

The undersigned participant and his/her parent/legal guardian warrant that the participant is physically fit and able to participate in all camp activities and that there is and will be adequate health insurance in force for the term of the camper's attendance. The undersigned further verifies
that the health insurance covers any and all accidents, injuries, or illnesses that may result from participation in the camp activities and that the camp's medical form has been completed, signed, and dated.

The camper and his/her parent/legal give the MS District UPCI and its representatives permission to provide emergency medical response and /or treatment as needed for any injury or illness that may occur while the participant is involved in camp activities and agree to release the Mississippi District UPCI and its representatives from all liability arising out of such treatment.

In addition, as the participant's parent/legal guardian give the camper permission to participate in any and all District Approved camp activities, either on or off the campgrounds.

NEW THIS YEAR - All campers who pre-register for camp by May 6th will receive a FREE* camp T-Shirts, compliments of Save Our Children!

*For sizes up to Adult XL. Adult 2X and larger will incur a small fee.

T-Shirt Size

Running Total

$0.00

Processing Fee

$5.00

Coupon Code

Total

$5.00

Check-in/out Schedule

June 2nd - Sunday - 5PM-10PMEarly Camp Check-In

Campers can check in early on Sunday and participate in an informal Sunday Fun Night. Check in will be in the Tabernacle building.

June 3rd - Monday - 10:00AMRegular Camp Check-In

Follow the signs upon arriving at the campgrounds. Check in will be in the Tabernacle building.

June 7th - Friday - 9:00AMCamp Check-Out

Campers will check out at their respective dorms or at the camp office.

Days until camp:

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Speaker

Jumpin' Josh Combs

Location Information

Please acknowledge that you have read and consent to the following statements:

Check-in/out Schedule