2021 AK Winter Retreat Registration

2021 Winter Retreat Registration

These forms are required for your teenager to attend winter retreat.
Camper Name *

Last Name
Nickname
Date of Birth *

Month Day Year
Gener *

Male Female
Grade in 2020/2021 *
Church *
T-Shirt Size *
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Parents' Information

Parent/Guardian 1
Parent/Guardian 1 *

First Name Last Name
Relationship to Child *
E-mail *
Phone Number *

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2
Name

First Name Last Name
Relationship to Child *
Phone Number

Area Code Phone Number
Home Address Same as Parent/Guardian 1?

Yes
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contacts

Contact 1
Name *

First Name Last Name
Relationship to Child *
Phone Number *

Area Code Phone Number
Contact 2
Name *

First Name Last Name
Relationship to Child *
Phone Number *

Area Code Phone Number
Medical / Health Information
Insurance Carrier *
Policy Number *
Name of Physician or Clinic/Hospital *
Physician Phone Number *
Is the Camper up-to-date on all immunizations? *

Yes No
Date of Last Tetanus Vaccine? *

Month Day Year
Does your child have any food, medication or environmental allergies? *

Yes No
Allergies? Check all that apply *

Food Medication Environmental
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during camp? *

Yes No
If yes, does this medication, food supplement, or medical food need to be administered at camp? *

Yes No
Please explain *

0/150
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions. *

0/200
If deemed necessary by the camp nurse, the following medicatins may be given (check all that apply):

Tylenol Benadryl Caladryl Sunscreen Bug Spray
I further agree that my child can receive over-the-counter remedies. Please initial in the box if you do NOT want your child to receive over-the-counter medications
Wavier and Release
I wave any and all claims against Camp Maranatha, the Alaska District Church of the Nazarene, or any of its Boards, Committees, or its Representatives pertaining to this camp/retreat, for any personal injuries, property damage, losses, claims or theft, whether known or unknown regardless of the fault, cause or negligence of Camp Maranatha, which may have occurred on the grounds of Camp Maranatha.

I agree to indemnify and hold Camp Maranatha, harmless from all losses, liabilities, damages, costs or expenses, (including but not limited to reasonable attorneys' fees and other litigation costs and expenses) incurred as a result of any claims or suits that we (or anyone claiming by, under or through me) may bring against Camp Maranatha, regardless of cause.
I grant the Alaska District NYI, Camp Maranatha, and/or the Alaska District Church of the Nazarene permission to photograph or video my dependent and use the photo and/or other digital reproduction nof him/her for publication processes, whether electronic, print, digital or electronic publishing via the internet. *
Type first and last name above to consent
I have read and reviewed this Wavier and Release Agreement. I have fully read and understand my obligations stated therein. I agree that I am legally able to execute it. I agree that my electronic signature shall be as valid as a pen-and-paper signature.
Sign Document *
Date Signed *

Month Day Year
Payment Options *

Check - made out to Alaska NYI and mailed to Adam Ziegler, 1220 E St, Anchorage, AK 99501 (if paying by check then leave the last question blank) Church Paying as a Group (if paying by group then leave below blank) Online - see below
Online Payment Options (Paying online only. Leave blank if paying by check or as a group)
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Early Bird Registration (Before January 1st, 2021) $ 80.00

Regular Registration (after January 1st, 2021) $ 100.00

Total $ 0.00
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2021 Winter Retreat Registration

Parents' Information

Emergency Contacts

Medical / Health Information

Wavier and Release