Expedition Summer Day Camp Registration Form
Child’s Information (Please print)
Name Last:
First:
Middle:
Male/Female______________________Birth Date:
Age:
Grade in Fall: __________________________________
Parent/Guardian Information
Mother/Guardian Name:
Mailing Address:
Phone Home:
City:
State:
Work:
Zip:
Cell:
E-Mail:
Father/Guardian Name:
Mailing Address:
Phone Home:
City:
State:
Work:
Zip:
Cell:
E-Mail:
Medical Information
PARTICIPANT INFORMATION
Participant Name:
Parent/Guardian:
E-mail:
Age:
Address:
Date of Birth:
EMERGENCY CONTACT INFORMATION
Contact # 1: ___________________________________ Relationship to Participant:
Primary Phone
__________________ (Cell / Home / Work)
Secondary Phone: __________________ (Cell / Home / Work)
Contact # 2: ___________________________________ Relationship to Participant:
Primary Phone
__________________ (Cell / Home / Work)
Secondary Phone: __________________ (Cell / Home / Work)
Parent
Guardian
Other: ______
Parent
Guardian
Other: ______
INSURANCE INFORMATION
Medical Insurance Carrier:
Policy/Group Number:
Primary Insured SSN:
Carrier Phone:
Primary Insured:
Relationship to Participant:
PARTICIPANT HEALTH HISTORY
Please check yes or no if participant has or has had a history of the following:
Asthma*
Heart Defect/Disease*
Seizures*
Diabetes*
Recent Hospitalization*
Under Doctors Care*
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
ADD/ADHD
Head Lice (recent)
Sleep Walking
Tuberculosis
Headaches
Fainting
Ear Infections

Yes
Yes
Yes
Yes
Yes
Yes
Yes
* Please note: We require a Written Authorization Form to be completed by a
Physician prior to arrival at camp for bold* items which have been checked “Yes.”
Immunization History/Dates:
Tetanus/Dtap/DT/Td: _____ Polio: _____ MMR: _____ TB/Result: _____ Chicken Pox: _____ Flu Vaccine: _____
No
No
No
No
No
No
No
Allergies / Medications / Dietary Restrictions
Are there allergies to any medications, foods, Bee stings, etc., or dietary restrictions?
Yes
No (If yes, please explain below)
List Allergy/Restriction: __________________________ Reaction: ___________________________________________________
List Allergy/Restriction: __________________________ Reaction: ___________________________________________________
List Allergy/Restriction: __________________________ Reaction: ___________________________________________________
Are there any restrictions for medical
reason?
Yes
No List:
Are there any behavioral/psychological
concerns?
Yes
No List:
Does the Participant have any conditions requiring regular medication?
No
Medication: ___________________________
Dose: _____
Frequency: _____
Reason for taking medication:
_______________________________________________
Medication: ___________________________
Dose: _____
Frequency: _____
Reason for taking medication:
_______________________________________________
Medication: _____________________
Dose: _____
Frequency: _____
Reason for taking medication:
_______________________________________________
You may administer the following medications to my Participant:
Tylenol
Benadryl
Advil
Motrin
Ibuprofen
My Participant cannot participate in the following activities for medical reasons:
Swimming
Hiking
Games
Climbing/Ropes Course
Lifting
Cold Medications
Dirt Scooters
Yes
Other:_______________
Paintball
Other:__________
Please comment on current Mental, Psychological, or Medical Conditions requiring medication, treatment, or special consideration
while at camp _____________________________________________________________________________________________
PARENT/GUARDIAN AUTHORIZATION
THE FOLLOWING MUST BE COMPLETED: Unless this form is signed by a parent or
guardian, Pine Valley cannot get emergency help for your child in case of injury. This technical
wording is controlled by the dictates of State Law. Thank you for your cooperation.
This health history is correct and complete as far as I know. The person herein described
has permission to engage in all camp activities except as noted.
I hereby give permission to the camp to provide routine health care, administer prescribed
medications and seek emergency medical treatment including ordering x-rays or routine
tests. I agree to the release of any records necessary for insurance purposes. I give
permission to the camp to arrange necessary related transportation for me/my child.
In the event I cannot be reached in an emergency, I hereby give permission to the physician
selected by the camp to secure and administer treatment, including hospitalization, for the
person named above. This completed form may be photocopied for trips out of camp.
I, the undersigned parent/person having legal custody/guardianship of the above named
minor, hereby give permission for the minor to participate in the Camping Programs of Pine
Valley Bible Conference Center (PVBCC). I give permission for photographs or video
footage of my child to be used by the camp for promotional purposes and placed on the
PVBCC web page for parents. I understand that the program includes such activities as
swimming, hiking and group games. The minor is physically able and mentally prepared to
participate in all camp activities. I hereby voluntarily and knowingly assume all risks and
dangers inherent and incidental to the activities of the camp program. I will not hold Pine
Valley Bible Conference Center liable for any injuries incurred during the program whether
caused by equipment or acts of omission of others excepting damage or injury solely caused
by the willful misconduct or negligence of Pine Valley Bible Conference Center or its
employees or agents.
Printed Name of parent/Guardian: _________________________________
Signature of Parent/Guardian:
_________________________________
Date: _________________
PHYSICIAN WRITTEN AUTHORIZATION FORM
Required to be completed by a Physician ONLY IF Participant has a history of asthma, heart
disease/defect, seizures, diabetes, has been recently hospitalized, or is currently under a physician’s care.
Please Note: Because of the Participant’s medical history, we have asked for your written authorization prior to the Participant’s
attendance. The program consists of a variety of activities including: Swimming, hiking, games, climbing/Ropes Course, lifting, dirt
scooters, paintball, and other activities around camp.
Your careful consideration is appreciated.
Remarks:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____
Date of last Tetanus booster:__________
Are there any restrictions in any physical programs (e.g. Swimming, hiking, games, climbing, lifting, etc.)?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____
I have examined the application for entrance to Pine Valley Bible Conference Center
and find the individual physically qualified to be accepted as a camper/staffer into all
camp activities except as noted.
Printed Name of Physician: _____________________________ Phone: ___________
Signature of Physician:
_____________________________ Date: ___________
Day Camp Information/Payment
Monday-Friday Program 8a.m. to 5p.m. INCLUDES LUNCH & SNACK is $150 per week
My Child Has Permission to Swim
Y
Sibling Discount: 2nd child is $100 per week
N
YOU CAN ALSO CALL VONIE AT 619-473-9933 TO MAKE PAYMENTS.
Names of persons who have permission for pick up from day camp: (Persons must be listed or we won’t release your child)
1. Name:
Cell:
2. Name:
Cell:
3. Name:
Cell:
Statement of Responsibility for Camper
I promise to participate in the day camp activities with enthusiasm, trying my best to model the attitude of Jesus Christ (Philippians 2:5). I promise
to obey the rules, which the camp has made for the best interest and safety for all including no violent behavior, no foul language, no disrespect to
day camp staff, and no alcohol, drugs, tobacco, weapons of any kind, cell phones, iPods, MP3 players, or other electronic devices.
Signature of Camper
Date:
Statement of Parent/Guardian
In signing this registration form, I hereby certify that the information is correct. I have read and understand the information page and the daily
schedule provided. I will abide by the refund policy of the day camp and I agree to pick up my child early in the case of illness or disciplinary
reasons.
I give permission for my child to participate in the activities of Expedition Day Camp at the PVBCC recognizing that there is an element of risk in
any activity that is outdoors.
I give permission for the use of photographs and video including my child to be used in publicity for the PVBCC newsletter, advertisements, and
Internet websites reporting on Expedition.
Understand that the information in this form is confidential and will only be seen by the parent/guardian of this camper and the Expedition Day
Camp staff of the PVBCC.
Payment and Cancellation Policy

We require payments be made a week ahead to ensure adequate staffing / You may pay by credit card at the
Ministries office or call Vonie at 619-473-9933
 To receive a refund or credit, we require 24 hr. notice of cancellation.
 If your cancellation is made with at least a week’s notice we will provide a full refund; if less than a week, we
will give you a credit.
Signature of Parent/Guardian
Date:
RELEASE OF LIABILITY FORM (MINORS)
PINE VALLEY BIBLE CAMP AND CONFERENCE CENTER hereinafter referred to as “PVBCC” requires a signature for all
attendees of the Camp. Furthermore this form releases PVBCC to photograph and/or use photographs of attendees for use in its
publications, advertising, promotional purposes, internet, and/or visual presentations which inform people of the services and activities
of PVBCC. The signature provided confirms Agreement to Attend, Participate, Assumption of Risk, and Release Form in order to attend
PVBCC and to participate in any PVBCC activity.
Attendee/Participants Name______________________________________________Age:___________
IN CONSIDERATION of attending PVBCC, I acknowledge, appreciate, and agree that:
1.
2.
3.
4.
Attendance and Activities at PVBCC may including but are not limited to basketball, swimming, strenuous competition
games, paint ball, ropes course, giant swing, night games, frisbee golf, walking, hiking, volleyball, and other Summer/Winter
related sports and activities. I realize that unanticipated and unexpected dangers may arise during and associated with the
above activities. I voluntarily agree to accept any and all risks of injury, death or damages of any nature resulting directly or
indirectly from participation in these activities.
I understand that attendance at PVBCC and participation in any PVBCC activities can be physically and mentally intense. I
understand the rules of play and will comply with all rules and regulations. If I observe any unusual or unnecessary hazard
during my participation, I will bring such to the attention of the nearest official as soon as practical; and,
I, for myself and on behalf of my heirs, assigns, personal representative and next of kin, HEREBY RELEASE AND HOLD
HARMLESS PINE VALLEY BIBLE CONFERENCE CENTER, their officers, officials, agents and/or employees
(“releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss of damage to person or
property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEE OR OTHERWISE, except that which is
the result of gross negligence and/or wonton misconduct.
I understand and agree that this Release of Liability Agreement covers attendance and each and every activity and event in
which I participate hereafter.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND
ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY
AND VOLUNTARIALY WITHOUT ANY INDUCEMENT.
Parent or guardian must read this form and sign below
This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree not only to his/her
release of Pine Valley Bible Conference Center and all other releases but also to release and indemnify the Releases from any and all
liabilities incident to his/her involvement in these programs for myself, my heirs, assigns and next of kin.
X_____________________________________________ Date Signed ___/___/___Relationship to Camper_____________________
Expedition Behavior Expectations
What you can expect from our staff:

We strive to praise, reward, encourage, and listen to your child

We will be calm, consistent, and objective when helping campers come under camp expectations.

We will model appropriate behavior

All behavior redirection will happen immediately, we will not withhold future privileges and activity time for current
behavior issues.

We will not tolerate bullying (Persistent exertion of social or physical dominance)
What we expect from your child:

Respect themselves, others campers, and camp staff

Listen and follow the leaders instructions

Strive to help create a positive environment that applauds the accomplishments of others and puts group fun above
individual fun.

No bullying of fellow campers or staff.

To stay on the Expedition grounds and with the group at all times.

To take responsibility for one’s actions and the effects they might have on others.
How our discipline system works:
If your child is involved in an incident that requires disciplinary action, the following three-strike system will be implemented:
1st Offense- Verbal warning, possible removal from current activity and discussion with parent
2nd Offense- Written warning, discussion with parent, and probation
3rd Offense- Discussion with parent and removal for the week without refunds
Physical violence, vulgarity, bullying, and destructive/perverse behavior will not be tolerated under any circumstance. These
incidents may carry a more severe penalty than above. Dependent on the situation’s severity, the Department may deem to move to 2nd
or 3rd offense consequences initially if it is in the best interest of the campers and staff.
_______________________________________________
Parent’s Signature
_______________
Date
PVBCC MINISTRY DIRECTOR: DAN BRAGDON 619-415-5959 OR [email protected]
PVBCC EXPEDITION DIRECTOR: CAREN MARTIN 619-820-6002 OR [email protected]
EXPEDITION REGISTRAR: VONIE GASS 619-473-9933 OR [email protected]