Youth Camp Registration 2025Youth Camp 2025 1 Attendee2 Family3 Registration4 Cancelation5 MedicalNumber of Attendees*123456Attendee 1Name* First Last Gender*MaleFemaleBirth Date* MM DD YYYYGrade recently completed*If your child is a recent graduate or will be going into 11th or 12th grade in fall, will they be attending the extra camp day, Tuesday June 17th?yesnoAdult T-shirt size*XSSMLXLXXLIs there any medical conditions or other limitations you would like us to aware of?List all medications with instructions, (Rx or over the counter) to be taken while at campMedicationInstructions List any allergies and the reactionAllergyReaction Does your child have to leave camp for any reason? Please explain.Any special instructions for your child?If not a Redeemer member, how did you find out about Redeemer Youth Camp?Attendee 2Name* First Last Gender*MaleFemaleBirth Date* MM DD YYYYGrade recently completed*If your child is a recent graduate or will be going into 11th or 12th grade in fall, will they be attending the extra camp day, Tuesday June 17th?yesnoAdult T-shirt size*XSSMLXLXXLIs there any medical conditions or other limitations you would like us to aware of?List all medications with instructions, (Rx or over the counter) to be taken while at campMedicationInstructions List any allergies and the reactionAllergyReaction Does your child have to leave camp for any reason? Please explain.Any special instructions for your child?If not a Redeemer member, how did you find out about Redeemer Youth Camp?Attendee 3Name* First Last Gender*MaleFemaleBirth Date* MM DD YYYYGrade recently completed*If your child is a recent graduate or will be going into 11th or 12th grade in fall, will they be attending the extra camp day, Tuesday June 17th?yesnoAdult T-shirt size*XSSMLXLXXLIs there any medical conditions or other limitations you would like us to aware of?List all medications with instructions, (Rx or over the counter) to be taken while at campMedicationInstructions List any allergies and the reactionAllergyReaction Does your child have to leave camp for any reason? Please explain.Any special instructions for your child?If not a Redeemer member, how did you find out about Redeemer Youth Camp?Attendee 4Name* First Last Gender*MaleFemaleBirth Date* MM DD YYYYGrade recently completed*If your child is a recent graduate or will be going into 11th or 12th grade in fall, will they be attending the extra camp day, Tuesday June 17th?yesnoAdult T-shirt size*XSSMLXLXXLIs there any medical conditions or other limitations you would like us to aware of?List all medications with instructions, (Rx or over the counter) to be taken while at campMedicationInstructions List any allergies and the reactionAllergyReaction Does your child have to leave camp for any reason? Please explain.Any special instructions for your child?If not a Redeemer member, how did you find out about Redeemer Youth Camp?Attendee 5Name* First Last Gender*MaleFemaleBirth Date* MM DD YYYYGrade recently completed*If your child is a recent graduate or will be going into 11th or 12th grade in fall, will they be attending the extra camp day, Tuesday June 17th?yesnoAdult T-shirt size*XSSMLXLXXLIs there any medical conditions or other limitations you would like us to aware of?List all medications with instructions, (Rx or over the counter) to be taken while at campMedicationInstructions List any allergies and the reactionAllergyReaction Does your child have to leave camp for any reason? Please explain.Any special instructions for your child?If not a Redeemer member how did you find out about Redeemer Youth Camp?Attendee 6Name* First Last Gender*MaleFemaleBirth Date* MM DD YYYYGrade recently completed*If your child is a recent graduate or will be going into 11th or 12th grade in fall, will they be attending the extra camp day, Tuesday June 17th?yesnoAdult T-shirt size*XSSMLXLXXLIs there any medical conditions or other limitations you would like us to aware of?List all medications with instructions, (Rx or over the counter) to be taken while at campMedicationInstructions List any allergies and the reactionAllergyReaction Does your child have to leave camp for any reason? Please explain.Any special instructions for your child?If not a Redeemer member, how did you find out about Redeemer Youth Camp?Parent Emergency ContactName* First Last Phone Number*Email Address* Non Parent Emergency ContactName* First Last Phone Number*Email Address PhysicianPrimary Physician First Last Physician's Phone NumberInsuranceInsurance CompanyInsurance Policy NumberInsurance Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Insurance PhoneSubscriber NameRegistrationRegistration (Per Attendee) Price: $175.00 The cost of registration includes food, lodging, rental of meeting facilities, and all activities.Payment Type*Credit CardCheck/Cash payable at check-inRequest ScholarshipDonations I would like to provide a tax deductible donation for families or guests who are unable to pay the full cost of the retreatDonation Amount Total $0.00 Scholarship RequestA limited number of scholarships are available. If you would like to apply for a partial or full scholarship, give reasons for the request. Forms must be turned in by June 9th to be eligible.I am able to pay:Request DetailsCredit CardA Credit Card Form will appear on the last page of this registration form for your paymentCheckPlease write a check to "Redeemer Community Church" with "Youth Camp" in the memo line.Please write an additional separate check to "Redeemer Community Church" with "Scholarship" in the memo line.I, the form signee, (parent or legal guardian) give permission for my child, the attendee of this form, to attend the Redeemer Community Church (“RCC”) summer youth camp at Dickson Valley Camp in Newark, Illinois from June 19, 2024 through June 22, 2024. I am aware of the usual dangers and risks inherent in summer youth camp activities and play. By signing this waiver, I freely accept and fully assume responsibility for all such dangers and risks and the possibility of personal injury, death, property damage or loss resulting therefrom. I hereby agree to release, indemnify and discharge Redeemer Community Church, its agents, administrators, and officers and their respective insurance carriers, representatives, and assignees, (hereinafter, “RCC”) on behalf of myself, my spouse, my child(ren), my heirs, assigns, personal representative and estate as follows: 1. I acknowledge that participation in overnight activities, games, and play activities entails known and unknown risks that could result in physical or emotional injury, paralysis, death, or damage to participants, to property or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, among other things: usual risk of cuts and bruises. Other more serious risks exist as well. I, and/or my child(ren) may sprain or break wrists, arms, legs and ankles, and can suffer more serious injuries as well. In any event, if I and/or my child(ren) are injured in any way, I and/or my child(ren) may require medical or other assistance at my own expense. While you are granted the right to inspect the facility, equipment and surrounding environment, RCC does not represent themselves as to having any special training or skill and may give incomplete warnings or instructions and the facility and equipment being used might be incorrectly assembled and/or malfunction. 2. I hereby assume all risks associated with my and my child(ren)’s participation at youth camp. Additionally, I agree to hold harmless, release, defend and indemnify RCC, its agents, administrators, and officers and their respective insurance carriers, representatives, and assignees, from any and all liability and/or claims for injury or death to persons or damage or loss to property arising from my and/or my child(ren)’s participation in the activity, including those claims based on RCC’s alleged or actual negligence or breach of any express or implied warranty. I expressly agree and promise to accept and assume all of the risks existing in this activity. My and/or my child(ren)’s participation in this activity is purely voluntary, and I and my child(ren) elect to participate in spite of the risks. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless RCC its agents, administrators, and officers and their respective insurance carriers, representatives, and assignees from any and all claims, demands or causes of action, which are in any way connected with my and my child(ren)’s participation in this activity or my use of the equipment or facilities, including any such claims which allege negligent acts or omissions of the aforementioned. Should RCC or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. 3. I certify that I and my child(ren) have adequate insurance to cover any injury or damage that I or my child(ren) may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical, physical or other condition that I and/or my child(ren) may have. 4. In the event that I file a lawsuit against RCC on behalf of myself or my child(ren), I agree to do so solely in the state of Illinois, and I further agree that the substantive law of Illinois shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. 5. I acknowledge that I am also signing this release on behalf of myself and my child(ren) identified herein and that I and my child(ren) shall be bound by all the terms of this release. Additionally by signing this release as the parent or legal guardian of a minor, I understand that I am waiving certain rights on behalf of my child(ren) that my child(ren) otherwise may have. I agree that but for the foregoing, my child(ren) would not be permitted to participation in the activity. 6. By signing this document, I acknowledge that if anyone is hurt or property damaged during my and/or my child(ren)’s participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against RCC on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms. Parent’s or Guardian’s additional indemnification: In consideration of being permitted by RCC to participate in the above-described activities and to use its equipment and facilities, I further agree to indemnify and hold harmless RCC from any and all claims which are brought by, or on behalf of myself and/or my child(ren), and which are in any way connected with such use or participation by myself and/or my child(ren). I have carefully read the foregoing legality release, understand its contents, and am aware that I am releasing certain legal rights that I otherwise may have.Signature*PaymentCredit Card Card Details Cardholder NameUntitledFirst ChoiceSecond ChoiceThird Choice
