Blank registration form.pub

2011 Registration Form
Both sides must be completed. Remember, You Can Register Online at www.CampACC.com!!!

Student’s Name _______________________________ Email ______________________________________
Office Use Only
Address __________________________________________________________________________________

City, State, Zip ___________________________________________Home Phone ( ____ ) ______________ Date Received _____________
Gender □M □F Date of Birth ______________ Grade Entering in Fall of 2011 ____________________ Paid in Advance ____________

Parent’s Name(s) __________________________________________________________________________ Check # __________________
*Parent’s Email ____________________________________________________________________________ Comments ________________
Lives with: □Both Parents □Mother □Father □Other _______________________________________ _________________________
Mother’s Work Phone ( ___ ) _________________ Mother’s Cell ( ____ ) ___________________________ _________________________

Father’s Work Phone ( ___ ) _________________ Father’s Cell ( ____ ) ___________________________
Emergency Contact Name _________________________ Phone ( ___ ) ___________________________

Church Name _______________________________ City _________________________________________ _________________________

Roommate Request 1. __________________________________ 2. _________________________________ _________________________
*Providing this address indicates your agreement to paperless confirmation. Please ensure your email filtering settings allow emails from campacc.com. Otherwise you must request printed confirmation of this registration. Please Choose a Session
Full payment or $100 non-refundable deposit is due on all sessions except for Day
Camp, Pee Wee, & Pathway (full tuition is due for these camps with this form).

Program Before After Church will pay - $ _______ Church representative signature
Session Director Dates April 1st April 1st
TruthQuest
Multi-Child Discount - _______ $ □ Day Camp 1 .Tempa Bader .June 25 . $45 . $55 □ Day Camp 2 .Kathy Thomason . July 16 . $45 . $55 ACC Scholarship - $ _______ All scholarships must be approved □ Pee Wee 1 .Beth Crouch .June 17-18 . $70 . $80 □ Pee Wee 2 .Amy Mullins . July 29-30 . $70 . $80 Total Tuition = $ _______
□ Middler .Justin Davis .June 12-16 . $205 . $225
□ Junior 1 .Heather Logan .June 19-24 . $255 . $275
Optional Items
Only mark items you are paying for with this form □ Junior 2 .Bob Barron . July 10-15 . $255 . $275 □ Junior 3 .Pat Johnson . July 24-29 . $255 . $275 Media Disc: $15 + $ _______ Includes all photos & Wilderness
□ Jr Wilderness 1 .Brandy Stykes .June 12-17 . $290 . $310 □ Jr Wilderness 2 .Jim Goehner .June 26-July 1 . $290 . $310 Canteen Deposit + $ _______ Canteen is not available for □ Jr Wilderness 3 .Erica McMurray . July 3-8 . $290 . $310 □ Jr Wilderness 4 .Alex Croghan . July 17-22 . $290 . $310 Scholarship Donation + $ _______ □ Jr Hi Wilderness 1 .Martie Roe .June 5-10 . $325 . $345
□ Jr Hi Wilderness 2 .Mike Beverly . July 3-8 . $325 . $345 Total Optional Items = $ _______
□ Jr Hi Wilderness 3 .Isaac Keebler . July 10-15 . $325 . $345 □ Jr Hi Wilderness 4 .Paul Cole . July 17-22 . $325 . $345 □ Sr Hi Wilderness 1 .Pat Absalom .June 12-17 . $325 . $345 □ Sr Hi Wilderness 2 .Paul Cole .June 19-24 . $325 . $345 Total Amount Due (Total Tuition + Total Optional Items) $ ______
□ Sr Hi Wilderness 3 .Josh Church .June 26-July 1 . $325 . $345 □ Sr Hi Wilderness 4 .Craig Shaw . July 24-29 . $325 . $345 Amount Enclosed With This Form $ ______
Payment Method:
□ Core 1 .Tommy Staggs .June 12-17 . $255 . $275 □ Cash □ Check □ MasterCard □ Visa □ Discover
□ Core 2 .Tom Peters .June 26-July 1 . $255 . $275 □ Core 3 .Brad Perry . July 17-22 . $255 . $275 Cardholder Name ___________________________________
Card # _____________________________________________
□ Summit .Brandon Perry .June 5-11 . $295 . $315 □ Sports Summit .John Dyer . July 3-8 . $255 . $275 Amt Charged __________________Exp Date _____________
Pathway
□ Pathway 1 .Evan Wolfe . May 29-June 11 . $80 . $100
___________________________________________________ □ Pathway 2 .Mike Luzadder .June 12-24 . $80 . $100 Church Representative Signature Date
□ Pathway 3 .Josh Elliott .June 26-July 8 . $80 . $100 □ Pathway 4 .Caleb Gilmore . July 10-22 . $80 . $100 ___________________________________________________ □ Pathway 5 .Brett Hyder . July 24-Aug 5 . $80 . $100 Church Name and City
Both sides must be completed. Remember, You Can Register Online at www.CampACC.com!!!
Student’s Name: _________________________________________________________________________________________ Student’s Physician: ___________________________________________________ Physician Phone: _____________________________ Insurance Carrier: ____________________________ Policy # _________________Tetanus Vaccination Date: ______________________ Allergies: ________________________________________________________________________________________________________ Additional Health Information: ______________________________________________________________________________________ _______________________________________________________________________________________________________________ Please list any specific persons who are NOT authorized to pickup your child _____________________________________________
1st-time Camper □Y □N If Yes, name of friend who invited you ______________________________________________________
T-Shirt Size: □YS □YM □YL □S □M □L □XL □XXL Please tell us how you heard about Camp ACC: □ Friend □ Church □ Radio □ TV □ Newspaper □ Other ______________________________ Over-the-counter Medication Release

Your initials/signature verifies that your child may receive the below initialed over-the-counter medications in the event
that he/she should need them during this camp session. The initialed medications will be administered according to the
manufacturer’s instructions.

Please initial those medications which can be administered to your child:
______ Tylenol (acetaminophen) . For minor pain
______ Ibuprofen . For minor aches or pain ______ Calamine lotion . For bug bites, poison ivy, or other itching rashes ______ 1% Hydrocortisone cream . For bug bites, poison ivy, or other itching rashes ______ Benadryl . For minor allergic reactions (runny nose, sneezing, itching/watery eyes) ______ Sting relief swab/liquid . For bug bites/stings ______ Maalox . For stomach ache (without vomiting/diarrhea) ______ Tums . For stomach ache (without vomiting/diarrhea) ______ Topical antibiotic ointment . For superficial cuts/scrapes ______ Aloe . For sunburn, skin irritation Wilderness Campers only:
________Immodium………………………… . For diarrhea
________Dramamine . For motion sickness
________Poison ivy block . For poison ivy prevention, treatment
I give my permission to Appalachian Christian Camp for: over the counter medications to be given to my child by the First Aid Attendant; medical treatment to be administered to my child in such Camp ACC Contact Information
case as deemed necessary by a trained medical professional; my child to be taken off campus for any camp related activity. I give my child permission to participate in all recreation activities, including but not limited to swimming, climbing on the indoor rock climbing wall, and participating in ropes course activities and I hereby release Appalachian Christian Camp of all liability from injuries that might occur during such activities. I also agree that by providing a “Parent’s Email”, that my confirmation material will be emailed and I understand that it is my responsibility to ensure that emails from campacc.com will pass through all filtering systems. I understand that cell phones & electronic devices are not allowed at Camp ACC, and to the best of my ability I will not allow my child to bring such devices. I further give the right to the Camp ACC staff to confiscate a cell phone or any other electronic device my child brings to camp, until the dismissal of the camp session. I understand that Appalachian Christian Camp provides secondary insurance for any injuries that occur during camp. I release all photos, videos and audio tapes of my child to Appalachian Christian Camp for promotional purposes. I certify the information on this

_____________________________________________________________
(Signature of Parent/Guardian) (Date)
This Form Must be Completed, Signed and Returned and Received by the Camp Office One Week Prior to the Start of Your
Camp Session in Order to Qualify for Express Check-in and to Avoid Standing in the Registration Line

Source: http://whcc.info/storage/11registrationform.pdf