2023 HYC Camper Form

We are excited to welcome your camper(s) back to Camp Eagle Rock this year!

Early Registration is open now through Sunday, April 30th.
Pricing is as follows:
Now through April 30th: $499
May 1st through May 21st: $525

Registration will close on Sunday, May 21st. No registrations will be accepted after this date.

Parent/Guardian Information

Please complete the questions below to provide information for the parent/guardian of the camper.

Parent Name

This address will receive a confirmation email

Address

Phone

Regular Registration Payment (Payment info collected at the bottom of this form): $525.00

Camper Information

Please complete the following questions to provide basic information for the camper.

Camper First Name

Camper Last Name

Camper Birthdate

Camper Gender

Female Male

If other, please provide your church name:

Grade (entering in Fall 2023)

Camper T-Shirt Size

Medical/Emergency Information

Please provide the following medical and emergency contact information as it pertains to your camper.

EMERGENCY CONTACT - Please provide the name of a second adult we can contact in case of an emergency.

EMERGENCY CONTACT - Phone Number

EMERGENCY CONTACT - Relation to Camper

Camper's Doctor Name

Camper's Doctor Phone Number

Medical Insurance Provider and Policy Number:

Are the camper immunizations current?

Yes No

Year of last TETANUS shot:

Does the camper have any allergies or medical conditions? (Drugs, Food, Environmental)

Yes No

If yes, please list allergies and describe symptoms. (Enter N/A if no allergies)

Does the camper need to take medication while at HYC?

Yes No

If yes, please provide medication name(s) and dosage for each:

MEDICATION POLICY: All medications, including OTC medications, may only be administered by the camp nurse. I agree to deliver all medications in a zip-lock bag, in their original packaging.

I understand and agree.

OTC MEDS CONSENT: Our nurses keep basic OTC medications on hand (Tylenol, Asprin, Pepto-Bismol, etc.) Do we have your permission to administer OTC medications as needed to your camper?

Yes No

Regarding dietary requests: While we try to accommodate dietary needs, due to the variety of diets and specific needs we are not always able to accommodate every situation. If your child has specific dietary needs please indicate those and a member of the camp staff will reach out to you.

If your camper is on a specific diet (vegetarian, GF, etc) please provide diet restrictions:

Does the camper have any special physical, mental, or emotional needs?

Yes No

If yes, please list and give details.

Would you like a pre-camp call from the camp director or medical personnel regarding your child's needs? (If you check yes, we will send you a separate form to collect additional details.)

Yes No

Camp Waivers

New this year: Camp Eagle Rock recently transitioned to new ownership, and now requires their own waiver for all camp attendees under the age of 18.

Please review the Camp Eagle Rock waiver here.

After reviewing the above waiver, please complete the three acknowledgments below; one for Camp Eagle Rock and the remaining two for the hosting church organization.

CAMP EAGLE ROCK WAIVER: I confirm that I have reviewed the Camp Eagle Rock Waiver (linked in the above description), and agree to the terms outlined therein. I understand that my confirmation will serve as an electronic signature for this waiver. I further state that I am over the age of 18 and have the parental or guardian authority to complete such a waiver.

I understand and agree.

CAMPER WAIVER: In the event of an accident or injury, I agree not to hold the Heartland ICOC churches or Heartland Youth Camps, or Camp Eagle Rock responsible for medical or recovery expenses related to said injury.

I understand and agree.

TRANSPORTATION WAIVER: I agree not to hold the Heartland ICOC churches, Heartland Youth Camps, or Camp Eagle Rock responsible for any accidents or injuries that may occur in the process of tranporting my camper to and from camp.

I understand and agree.

REFUND POLICY: I am now completing my registration. I understand that registrations are non-refundable and non-transferrable.

I understand and agree.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2023 HYC Camper Form

Description

Please Fix the Following