CAMPER INFORMATION
First Name:
Last Name:
Phone:  -   - 
Cell:  -   - 
Address:
Address:
City:
State:
Zip:
Email:
Local Church:

MISCELLANEOUS INFORMATION
Birthday:          
           

Weight:   Date
Weighed:
  Blood
Type:
  Most Recent
Tetanus Shot:
     

EMERGENCY CONTACT INFO
First Name:
Last Name:
Phone Number:  -   - 
Relationship to Camper:

INSURANCE INFO
Insurance Company:
Insurance ID #:
   

MEDICAL INFORMATION
Please Check Any Applicable:
Rheumatic Fever
Tuberculosis
Diabetic
Heart Issues
Ivy/Sumac Allergy
Seizures
Fainting
Asthma
Sleepwalking
Kidney Issues
ADD/ADHD
Please list allergies/illnesses:
Bee/Wasp Stings
Penicillin
I have NO known allergies.
I have allergy issues.
 
PLEASE NOTE: CONSENTS & RELEASES
TREATMENT RELEASE
    In case of medical emergency, through submitting this form, I consent to necessary and proper treatment, surgery and/or anesthetic by a licensed physician or health care professional for the individual named on this form.
     I Agree    I DO NOT Agree
RISK RELEASE
    Through submitting this form, I hereby assume all risks of injury, loss of life, and damage to persons or property attending SummerFire. I further release, indemnify, and hold harmless the owners of the premises, including without limitation staff/administration of SummerFire, any other Corporation or LLC member ("Owners") including Peerless Road Church of God of Prophecy and staff and / or administration of Peerless Road Church of God of Prophecy, from and against any and all liabilities, claims, demands, costs, losses, expenses, or compensation of whatever nature in connection with any loss, damage, or injuries to persons and property caused or sustained by me or members of my family.
     I Agree    I DO NOT Agree
RECREATION RELEASE
    For and in consideration of attendance at SummerFire by the camper named on this application, through submitting this form, we, the undersigned, do hereby release and discharge SummerFire, The Church of God of Prophecy (local, state, and international offices), the directors and all other staff members of the camp from any and all liability for any injuries suffered by the camper while in attendance at SummerFire and while using the swimming area for recreation. The camper and his/her parents, if the child is under the age of 18, agree that the camper has full consent and permission to swim, ski, boat, and all additional water sports, at the campsite while in attendance at SummerFire.
     I Agree    I DO NOT Agree
BAPTISM RELEASE
    Water baptism is offered to campers during camp. We, the Church of God of Prophecy, teach baptism as an outward expression of our commitment to follow Christ and His example. This does not make a person a Christian or a member of the church. Through submitting this form, the camper has my permission to be baptized.
     I Agree    I DO NOT Agree
CERTIFICATION AND UNDERSTANDING
    Through submitting this form, I certify that all the information provided on this application is accurate to the best of my knowledge. I understand that, in signing this application, I am agreeing to abide by all the policies and discipline of the camp (referring to all camps and retreats sponsored by the Church of God of Prophecy), it's administration, staff and personnel. Any conduct incompatible, inconsistent or conflicting with the mission of SummerFire (and Peerless Road Church of God of Prophecy) as a Christian camp will constitute reason or cause for dismissal from camp and/or the decision to refuse acceptance to future camps.
     I Agree    I DO NOT Agree
 
  Food:   Other:   Recent Illness:
     
       
 
PLEASE NOTE:
You will receive an email receipt from Form Tools <noreply@cogop.org> very soon. If you do not see it in your Inbox, please check your Junk Mail folder. If you do not see it in your Junk Mail folder, you may email us at ajones@peerlessroadchurch.com to request your receipt.
PAYMENT AGREEMENT
Your registration is not complete until payment is received in the PRC offices. Follow these steps:
  • Complete the application and click SUBMIT. You will be redirected to the PRC "Tithing & Offerings" page.
  • Choose "Click here for online giving".
  • Choose "SummerFire" as your fund.
  • Follow through the payment process.
 
YES, I HAVE READ THE PAYMENT AGREEMENT.
Registration NOT COMPLETE
until payment is received in PRC office.


One last thing before you go to the payment page....
what size t-shirt should we bring to you?
Small Medium Large x-Large