STUDENTAPPLICATIONAYMSUMMERCAMP2019

ImportantCampInformation–Pleasereadcarefully!

AssetforthbytheExecutivePresbyteryoftheAppalachianDistrictCounciloftheAssembliesofGod

RegistrationFees▪ $215RegularRegistration(Includes$85non-refundable,transferabledepositwithform.Balancedueuponarrival.)▪ $195EarlyRegistration(SameconditionsforRegularRegistration.Deadlines:JR/SR-June10,Kids-July8)

▪ FamilyPlan(appliestoimmediatefamilyonly&mustmeetEarlyRegistrationdeadlines):First2camperspayfullpriceandeachadditionalstudentcostwillbe$145.

▪ Additional$15latefeeforOn-siteRegistration(Thereisnoguaranteeofspaceavailableforanyon-siteregistrations!)

Refunds&Transfers▪ Duetoprogrammingcosts,refundsforstudentswhoareunabletoattendafullweekofcampmustberequestedaminimumof

sevendayspriortotheLirstdayofcamp.Refundsmustberequestedviaemailappydyd@suddenlinkmail.com.Refundswillbeissuedattheendofthecampingseasonminusthenon-refundabledepositof$85.Wecannotrefundmoniesforpartialattendancetoaweekofcamp.Norefundswillbegivenforexpelledstudents.Alltransferoffundsfromonestudenttoanothermustbedoneinadvanceandnoton-site.Notransferoffundswillbeallowedfromonecampyeartothenext.

RegistrationProcedures1) Completetheregistrationandhealthhistoryform.2) SecureALLrequiredsignatures(camper,parent/guardian,&pastor).Failuretocompletethiswilldelaytheregistration

processwhichcouldjeopardizeacceptancetocamp.

3) Sendthecompletedregistrationformandnon-refundablefeeof$85(madepayabletoAYM)toSUMMERCAMP,P.O.Box310,GHENT,WV,25843-0310NOPHONE,FAXOREMAILAPPLICATIONSWILLBEACCEPTED.(*Note:RegistrationisonaQirstcome/Qirstservebasis.On-site,non-registeredindividualscannotbeguaranteedaspotuntilallpre-registeredandwaitinglistcampershavebeenaccountedfor.)

4) NEW:ItisimperativetohaveallformsinthehandsofAYMinatimelymanner.Thelatefeewillnotbewaivedbylastminutephonecalls,texting,emailing,calling,and/orfaxingofnamesandapplications.Anoriginalsignedapplicationmustbeonpropertyforeachstudentfromthestartofcampforliabilitycoverage.

CampLocations▪ Jr./Sr.HighCamp:ChurchofGodStateCampground-Roanoke,VA(8018AngelLane,Roanoke,VA24019).TakeI-81

towardsRoanoketoExit146(Hollins).Ifyouarecomingfromthesouthturnleftandfromthenorthturnrightofftheexitramp.Attheforkintheroad,turnleftontoAngelLane.TheCOGofQiceandcampgroundwillappearshortlyontheright.

▪ KidsCamp:CampMaranatha–Dublin,VA(5900OakGrovePlace,Dublin,VA24084).TurnontoRoute100towardsDublinfromRoute460,Route11,orI-81.MergeontoUS-11N/BroadSt.andturnleftatOakGrovePl.Thecampgroundwillappearshortlyontheright.

Arrival&Departure▪ Registrationandroomassignmentsbeginat1PMonMonday.Roomcheck-inisfrom1-3PM.Nocampersaretobeonthe

groundsbeforethistime.AYMwillnotberesponsibleforanycampersbefore1pmMondayofcamp.TheQirstmealwillbedinnerat5:30pmforcampers&staffonly.

▪ Campconcludesat11AMonFridayfollowingthemorningchapelservice.AllcampersaretobeoffthegroundsbyNOON.AYMwillnotberesponsibleforcampersafterthistime.BreakfastFridaymorningwillbetheQinalmealserved.

WhattoBring □Bible□Spendingmoney□Clothes,shoes,andswimsuitforafternoonrecreation □Towels&beachtowel □Personalarticles□Appropriateattirefor4eveningservices □Soap/Shampoo□Lightsweater/jacket □Pillow,sleepingbag&sheetsfortwinsizebed□Sunblock□OptionalItems:umbrella,camera

▪ MarkALLpersonalitems.AYMwillNOTberesponsibleforpossessionslostorstolenduringcamp.Leavevaluablesathome!

▪ Forspendingmoney,snackshackfood,t-shirts,andothercampstoreitemswillbesold.Itishighlyrecommendedthatcampershavespendingmoney($25ormore).

WhatNOTtoBring▪ Cellphones,iPods,mp3players,computers,videogames,hoverboards,watergunsorballoons,eireworks,non-

prescriptiondrugs,immodestorquestionableclothing,snacks,weaponsofanykind,alcoholicbeverages,andtobaccoproducts.(TheseitemswillbeconQiscatediffoundandretainedinanappropriateway)

▪ Wereservetherighttoinspecthousingareasifthereisanyreasonablesuspicion.Lackofcooperation,unnecessaryroughness,disregardforcamprules,ordamagetocamppropertywillresultinautomaticexpulsionfromcamp.Parentswillberesponsiblefordamageexpensesandcamper’stransportationhome.

ClothingPolicy▪ Clothingmustcovertheshoulders,back,sides,andnavelatalltimes.Nospaghettistrapshirtsorhalter-topswillbeallowedat

anytime.Sleevelessshirtswillbeallowedaslongastheycovertheshouldersduringtheday,butnotduringeveningservice.

▪ Nolowcuttopsordresses,hiphuggerpants,orleggingswillbeallowed.Shortsmustbeofmodestlength.

▪ Clothingwithobsceneorlewdgraphicsorsayingswillnotbeallowed,aswellasanythingpromotingalcohol,tobacco,orillegalsubstanceuse.

▪ Properattirefortheeveningserviceswillbejeans,dresspants,capripants,dresses,skirtsbelowtheknee,andmodestshirtsandshorts.Hatsorvisorsmaynotbewornduringeveningservices.

▪ Poolattire:Swimwearmustbemodest.AT-shirtwillberequiredoverimmodestsuits.Shirt,shorts,andshoesmustbeworntoandfromthepoolarea.

▪ AllinappropriateclothingwillbesubjecttoeinalapprovaloftheDYD.

CampHealthPolicy▪ Duetoverycloselivingconditions,majordisruptionsoccurwhenthereisahealthproblem.Studentswithcontagioushealth

problems(i.e.impetigo,lice,etc.)WILLBESENTHOME.Itisrecommendedthatthesesituationsbemonitoredbeforeleavingforcamp.Allcampswillhavecompletechecksbeforeregistrationtakesplace.Pleasehelpusavoidembarrassingsituationsofhavingtoeithernotadmitorsendacamperhome.

▪ TheAYMlicecheckformMUSTbeLilledoutandbroughttoregistrationthedayofcampbyyourleader.Alicecheckmustbeperformedonallpotentialcampersthedayofcamparrival.Theycannotbesentwiththecampapplicationinadvance.

▪ Intheeventofaninjuryorillnessthatrequirestheattentionofanemergencyroomorphysician,parentswillbenotiLiedassoonaspossible.

HousingPolicy▪ ALLstudentswillbehousedbeforearrivingonthecampgroundsonaLirstcomeLirstservebasis.Add-onscannotbeguaranteed

housingwiththeirgroup.Wewilldoourbesttoaccommodatehousing,butNOGUARANTEES!

NEWINFO:PleaseRead!VisitorPolicy&WorkerScreeningOur district is aware about the need to protect minors even in the atmosphere of the church world. We must recognize that abuse could happen even in summer camps and we must take every precaution necessary to reduce the likelihood of it happening. Therefore, every camp staff member must take the “Child/Youth/At Risk Abuse Awareness” (aka “Reducing the Risk”) training prior to their particular week of camp(s), and have a background check on file with our district office. *Background checks must be obtained through your local church affiliation, and must be renewed every three years.

▪ Duringcamp,parentsareaskedtorefrainfromvisitingandcallingchildren.Experiencesindicatethattheseallowances,aswellaschildrenaskingtocallhome,oftenpromotehomesickness.Incaseofanemergencyathome,callAdamPelfrey,theDistrictYouthDirector,at304-731-9379.

▪ InSeptember2014,theDistrictPresbytery,inconjunctionwithAppalachianDistrictCouncilandYCEDepartmentmovedtoclosethecamptooutsidevisitors.Wewanttotakeeveryprecautionnecessarytoinsurethesafetyofourstudents.Visitorsarenotpermittedonthepropertyatanytimeduringtheweekofcampandwillbeaskedtoleavethegrounds.

Formoreapplicationsvisitappyouth.com

2019SummerCampApplicationSELECTONECAMP&PLEASEPRINTCLEARLY!

CamperInformation

REGISTRATION FEES (Check one that applies—Deposit fee is due upon registration,Makecheckspayableto“AYM”)

___$195EarlyRegistration___$215RegularRegistration___$145FamilyPlan(CheckthisONLYifstudentisthethirdcamperorbeyondintheirimmediatefamily.Pleaselistthefamilymemberswhoarepayingasthe1stand2ndfamilymembers:________________and___________________.)

MandatoryDeposit$85$_______CampT-shirt$12$_______(Non-refundable,transferrable)(Circleasize)

YouthSizes:YS,YM,YLAdultSizes:S,M,L,XL,2XL,3XL

TOTALENCLOSED $_______OFFICEUSE:_______________

□Jr/SrHighCamp• 6/24-6/28• Ages12-18• EarlyRegistrationDeadline:June10,

2019

□KidsCamp• 7/22-7/26• Ages7-11• EarlyRegistrationDeadline:July8,2019

LastName: FirstName:

BirthGender(M/F): Age: Birthdate(MM/DD/YY):

UpcomingSchool: UpcomingGradelevel:

HomeAddress:

City: State: Zip:

HomePhoneNumber: EmailAddress:

Parent/GuardianName: Parent/GuardianWork/CellPhoneNumber:

EmergencyContact: EmergencyContactPhoneNumber:

ChurchName: ChurchCity: ChurchState:

1stDesiredRoommate: 2ndDesiredRoommate:

MedicalInformation

***TheAppalachianDistrictoftheAssembliesofGodprovidesSECONDARYHEALTHINSURANCEforallcampers.

➢ Pleasecheckthecommunicablediseasesthiscamperhashad:

□Measles□Polio□Mumps □ChickenPox □ScarletFever □WhoopingCough□Other:_______________

➢ Pleaseindicatetheyearthiscamperreceivedthefollowingimmunizations:

_______Diphtheria________WhoopingCough________Polio________Tetanus

➢ Pleasecheckifcamperhasanyofthefollowing:

□Appendicitis □HeartTrouble □EarTrouble □Asthma□Hernia□SkinTrouble□Allergies

□LungTrouble□HIV/AIDS□Other:___________________

***Onaseparatepieceofpaper,pleaseexplainanycheckeditemsANDlistanymedications(name/reason/instructions)camperistaking.

➢ Pleasecheckifcamperhasproblemswithanyofthefollowing:

□HeartTrouble□HighBloodPressure□SkinTrouble□Diabetes□Seizures□MigraineHeadaches

□Bedwetting□EarTrouble□Nosebleeds□Headaches□Kidneys□Fainting

□Sinus□Backproblems□Stings(allergic)□Asthma(musthaveinhaler)

➢ Ifnecessary,OTCmedicationsmaybegivenformildcomplaints(i.e.headaches,stomachaches,etc.).Pleaseindicatewhichmedicationsarepreferred:

□Tylenol□Ibuprofen□Tums□Pepto-Bismol□Other:_______________________

➢

➢

Physician’sName: Physician’sPhone:

InsuranceCarrier: InsuranceCarrierPhone:

PolicyNumber: GroupNumber:

SpecialMedications:

Allergies:

TypeofReaction(s):

TreatmentGiven:

PhysicalHandicaps,Disorders,orDiseases:

RestrictedActivities:

➢ Allmedicationsbroughttocampshouldbeclearlylabeledintheoriginalcontainerwithcamper’sname,prescribingphysician,prescriptionnumber,dateprescribed,medication,anddirectionsforuse.Allmedicationsarekeptinasecurelocationanddispensedbythecampnursingstaff.ApicturewillbetakenofcampersforidentiSicationpurposesandtheymustknowtheirbirthdateformedicaladministration.

➢ Camperswillbetakentoalocalimmediatecareclinicorhospitalemergencyclinicfortreatmentwhensickorinjured.

➢ PleaseDONOTsendyourchildtocampiftheyhaveafeveroranythingcontagiousincludingskinrashes,fungus,lice,etc.Ifachildmissescampduetosicknessandhaspaidinadvance,thereisaNOrefundpolicy.

AuthorizationandSignatures

I have read the attached information, and I will abide by ALL camp rules. I understand that violation of these guidelines may result in my dismissal from camp.

Camper Signature___________________________________________________________

I have read the attached information in regards to my child’s attendance at summer camp. I understand that although campers are under careful supervision, accidents may happen. I’m willing to assume that risk. I give consent for my child to participate in any camp activities, on and off campus. This medical form is correct, as far as I know, and the person herein described has permission to engage in all prescribed activities aside from those noted. IN CASE OF EMERGENCY, I hereby give my consent, in the event that all reasonable attempts to contact me have been unsuccessful, for the administration of any treatment deemed necessary by the appropriate licensed physician, dentist, or emergency personnel.

By my signature, I release the Appalachian District Council of the Assemblies of God and its officers from any liability in case of injury or harm to my child, which is not the result of gross negligence by a camp staff member. I also acknowledge I am personally responsible for any damage to camp property or facilities caused by my student. I authorize the Appalachian District Council to use this child’s image in photographs or video in any of its publications or other media.

Parent/Guardian Signature___________________________________________________ Date___________________

I hereby endorse that the camp applicant is in good standing with the Assemblies of God church I pastor.

Pastor Signature________________________________________________________________

INCOMPLETEAPPLICATIONSWILLBERETURNEDAND

MUSTBERESUBMITTEDBEFOREACCEPTANCE.