Register

Personal Information

Name*

First Last

Address*

Street Address City State ZIP Code

Age*

Male or Female?*

Shirt Size

Phone*

Email*

Price*

Would you like to register a sibling?

Yes

Name*

First Last

Age*

Male or Female?*

Shirt Size

Phone*

Email*

Price*

Would you like to register another sibling?

Yes

Name*

First Last

Age*

Male or Female?*

Phone*

Email*

Price*

Emergency Contact Name*

Phone*

Relationship to Camper*

Alternate Emergency Contact Name*

Phone*

Relationship to Camper*

Parent/Guardian Name*

Phone*

Home Church (please put "none" if applicable)*

Who is your Pastor (please put "none" if applicable)*

Pastor's Phone

Pastor's Email

Camp Tri State is committed to providing a safe camping experience and reserves the right to deny participation of any and all activities to any individual if in the opinion of camp leadership, their participation represents a hazard to themselves or others.

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Health Insurance Provider*

Policy Number*

Upload a picture of insurance card (optional but helpful)

Drop files here or

Max. file size: 512 MB.

Year of most recent tetanus booster*

Environmental Allergies

Medication allergies

Chronic illness

Covid 19 Vaccine

Send campers medications in original bottle(s) with directions on the bottles. Camp personal will hold and dispense all medications. If there is any other medical information that the nurse or first aid person would need to know about the camper, please contact Camptristate1@gmail.com. For promotional purposes, videos and photographs are taken at all events and services. Your registration constitutes permission for camp Tri State to use your picture in promotional materials. Except for gross negligence on the part of Camp Tri State, the participant or parent/guardian accepts personal financial responabilty for any bodily injury sustained at camp. Further, the participant or parent/guardian promises to hold harmless Camp Tri State and its representatives for any injury related to the activity. If a dispute over this agreement or any claim for damages arises, the participant or parent/guardian agrees to resolve the matter through mutually acceptable arbitration.

I hereby release the camper(s) named above into the care of camp personnel and give my permission for him/her to be treated by camp first aid personnel and/or hospital or physician assigned in case of medical emergency. I/We assume full responabilty for the cost of any emergency medical treatments and recognizes that every attempt will be made to reach me/us in case of emergency.

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Parent/Guardian Signature*

Date*

Total

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Number