June 17-24,
2017
Red River Valley Honors Camp
Camper Registration
OFFICE USE ONLY
Date _____ Chk# _____ Amt. _____
Bogg Springs Baptist Camp, Wickes, Arkansas 71973
Balance ________
Entering 6th Grade through High School (Just Graduated)
Date _____ Chk# _____ Amt. _____
Mail this form to Henri Pousardien (See address below)
Please use a pen and print clearly.
CAMPER INFORMATION
Applicant’s Full Name: __________________________________________ Date of Birth:__________________ Age: _____________
Name or nickname you prefer to be called (if different from above): _______________________
Male Female (circle one)
Address: _________________________________________ City: ____________________________ State: _______ Zip:______________
Home Phone: (_____) ________________________ Family E-mail address: ________________________________________________
Additional phone numbers (cell, work, etc.): ________________________________________________________________________________
(circle one) Grade next fall: 6 7 8 9 10 11 12 Graduate
T-Shirt Size: Youth(14-16) Adult: S M L XL XXL
Select ONE cabin-mate in your age/grade level and give their full name __________________________________________________
Two campers should request each other for a sure match. Trying to chain-link over three campers will not be honored.
Which translation of the Bible do you prefer to memorize from: KJV NKJV NIV(1984) ESV
Name of designated person picking up Camper: ________________________________________ ______________________________________
Primary Person
Alternate Person
A nonrefundable $100 registration fee is due with each registration. Final payments postmarked and paid in full by May 1
receive a $20 per camper discount. After May 1 the total camp fee for campers entering 6th-8th grade is $100 + $165 = $265.
After May 1 the total camp fee for campers entering 9th-HS graduate is $100 + $175 = $275.
Partial scholarship information for first year campers is available at www.RRVHC.com
Before you mail this form, make sure you 1. Fill out ALL the information on “this” form, the “Dress Code” form, and the “Parental
Consent and Release of Liability” form—otherwise the application is incomplete; 2. Enclose the $100 registration fee
(nonrefundable). Make check payable to “RRVHC”. Then mail all to Camp Commander: Henri Pousardien, ATTN: RRVHC, 1105 East “H”
Avenue, North Little Rock, AR 72116-8227. Note: this is not the location of the camp.
Note: receive $20 discount if balance of the camp fee is paid and POSTMARKED by May 1, 2017. Reservation and camp fees paid after
this date will result in camper being placed on standby and cabin assignment with a cabin-mate is delayed. If you have any questions
contact Henri Pousardien at email: [email protected], Web Site: WWW.RRVHC.COM or phone: 501-753-6577.
We recommend that you keep a copy for your records.
TO BE FILLED OUT BY APPLICANT’S AWANA MINISTRY DIRECTOR (COMMANDER)
Church: ___________________________________________________________________________ Awana Registration Number: ____________________
Church Address: _________________________________________________ City: ______________________________ State: _______ Zip: _____________
First year campers must have earned at least the Awana Excellence award or come as a guest and be age 10 for junior high and age 13
for high school. Returning campers must complete (before camp) the next handbook/manual in the current progression this club. Guests
must complete the age appropriate entrance brochure. Please complete the following to confirm your qualification for camp:
Past awards and expected award this year: Excellence
Timothy
Meritorious
Citation (Bring your Citation Award to camp)
Camper will complete the following age appropriate handbook/manual before camp or is a guest of the following camper: _______________
•Which Ultimate Adventure or Challenge book will you complete this year? _________________
•Which Trek Bible study will you compete this year. _________________
•What two Journey Bible studies will you complete this year.
_________________ _________________
Guest campers must complete and check the applicable requirements: T&T Start Zone
Trek Check
Faith Foundation
I confirm that this Applicant has/will have met camp qualification requirements and recommend her/him for Honors Camp. I
further confirm that the Applicant and/or the Applicant’s family have completed this Application and have provided all
necessary signatures and information, and that I have not signed on behalf of the Applicant or parents/guardians unless the
Applicant is my child.
_________________________________________________________________________
Signature (IF LEFT BLANK THE APPLICATION WILL NOT BE ACCEPTED)
__________________________________
Title (Director)
(_____) _____________________________
Phone number (of signatory)
______________________________________
Email address (of signatory)
————————————————————–
Red River Valley Honors Camp (RRVHC) is not operated by, associated with, or have any connection, legal or otherwise, with Awana Clubs International (ACI),
Inc. However campers must have achieved certain ACI qualifications to attend RRVHC that are attainable through their home school group and/or local church
and as verified by their local church Awana leaders. Moreover, RRVHC is a member of Christian Scholars Camp Ministries Inc. (CSCMI), a Dimension Ministries
Partner of 24-7 Ministries, the youth ministry, of ACI.
RED RIVER VALLEY HONORS CAMP
DRESS CODE
Parents: Please read, sign, and mail the bottom of this form with the camp application!
Campers (and parents) are required to exercise discretion and modesty regarding the selection of camper's
clothing. Christian young people can hurt their testimony and possibly offend others by the clothing they
wear and the way in which it is worn. Outfits, which are too tight, too short, or offensively imprinted, although not intentionally worn to be provocative, nonetheless often are. As such, they are not honoring to
the Lord, and should be avoided. With this in mind, the following dress code will be used at Honors
Camp.
Girls
•
•
•
•
•
•
All shirts and blouses must have sleeves.
Halter-tops, bare-midriff, or tightly form fitting clothing are not allowed.
Shorts are acceptable, but must be no shorter than three (3) inches above the knee (approximately the
width of a dollar bill above the knee). Shorts must also be of the loose fitting “walking shorts” variety
and not split-sided jogging shorts, or “spandex” style bicycle shorts alone or under other shorts.
Dresses must be at least the same length as the shorts described above.
T-shirts and other garments with “worldly writing or language” are not allowed.
Swimwear—one-piece with full front lining is preferred. A tankini style two-piece suit that completely covers the midriff area, with full front lining is acceptable. Both must meet the following guidelines: No cut-offs, plunging necklines, and/or high-cut leg openings are allowed. A cover shirt must be
worn to and from the pool.
Boys
•
•
•
•
T-shirts and other garments with “worldly writing or language” are not allowed.
All shirts must have sleeves.
Shorts are acceptable, but must be no shorter than three (3) inches above the knee (approximately the
width of a dollar bill above the knee). Shorts must also be of the loose fitting “walking shorts” variety
and not split-sided jogging shorts, or “spandex” style bicycle shorts alone or under other shorts.
Race-type swimwear (tank suit) is not allowed. No cut-offs are allowed in the pool. A cover shirt must
be worn to and from the pool.
This dress code is not intended to be “heavy-handed” or restrictive, but it is for the purpose of avoiding
any problems before they start. If there is any question about any article(s) of clothing, the camper's counselor will speak to him/her about it privately. In all cases, the Camp Commander’s word will be final.
THANK YOU FOR YOUR COOPERATION —WE APPRECIATE IT!
PARENTS: Please sign below:
I have completely read and understand the information above. I will make sure my son/daughter will have all the
clothes for the eight days of camp and adhere to the dress code above.
Signature of parent or guardian
_____________________________________________
This form must be signed before a cabin will be assigned. Thank you.
If you have any questions, please feel free to contact your Camp Commander.
Red River Valley Honors Camp
Parental Consent and Release of Liability
Please Print and Provide All Information Requested
IMPORTANT: THIS DOCUMENT CONTAINS A RELEASE OF LIABILITY. YOU ARE ADVISED TO REVIEW IT CAREFULLY.
Name of Camper ____________________________________
Camp Location Bogg Springs , Wickes, AR
Camper’s Date of Birth_______________________________
Dates Camper Will Attend Camp
June 17-24, 2017
I understand and agree that participation in the Red River Valley Honors Camp (“Camp”) is a privilege to which my
minor child named above (“Camper”) is not otherwise entitled. In consideration for that privilege, I am signing this
Parental Consent and Release of Liability.
Consent to Attend Camp
I hereby give permission for Camper to attend and participate in the Camp.
Consent to Medical Treatment
If Camper experiences an injury or illness, or has other medical needs, I authorize the Camp’s employees, volunteers, and agents to make such arrangements for Camper’s health and safety, including but not limited to first
aid, emergency medical care, ambulance or other transportation to a hospital, medical office, or clinic, testing and
examination, and hospital care, and other medical care and treatment (including dental care) as they feel are appropriate in the circumstances. I further agree that I am fully responsible to pay all charges and expenses relating
to such care, transportation and treatment and I hereby fully release Red River Valley Honors Camp and its directors, officers, employees, volunteers and agents from any claims, including claims for medical charges, prescription costs and other expense, I might have as a result of such care, transportation and treatment. My signature
below also serves to indicate my willingness for my Health Insurance Company (please provide details in the Medical Information section) to be billed for any and all medical fees and services should they be needed. I agree that
I will pay all charges and expenses not covered by insurance.
Medical Information
Medical Insurance Co.______________________________________
Policy Number______________________________
(Please attach a copy, front and back, of your insurance card. If you have no insurance please write “None”.)
Address_____________________________________________________________________________________________________
Phone (
)
-
Insured’s Name____________________________________
Doctor’s Name____________________________________________
Date of last tetanus (no more than 10 years)
Phone (
)
-
.
______________________ Date of last physical________________________
List any medical or food allergies of Camper (please write “None” if applicable):________________________________
_____________________________________________________________________________________________________________
Please list any special needs or accommodations (dyslexia, Asperger’s, etc.) that the camper may have or we need to be aware of:_______
______________________________________________________________________________________________________________
Will Camper be under any medication* while at camp? Yes
No
If yes, please provide details:____________
______________________________________________________________________________________________________________
*All medications are to be in original containers with prescription attached and given to the camp nurse.
The camp nurse has our (my) permission to provide Camper with non-prescription medicines as deemed
necessary. Yes
No
Please list any over-the-counter medicines that should not be given to Camper.
_____________________________________________________________________________________________________________
Does Camper have any physical condition or limitations that would restrict participation in any camp activities?
Yes
No
If yes, please provide details:_______________________________________________________________
_____________________________________________________________________________________________________________
Release of Liability
Prior to Camper’s participation in Camp activities, I acknowledge that involvement of Camper in the Camp may involve risk of property damage and of personal injury, illness or even death of Camper, including but not limited to
the risks arising from transportation–related activities, recreational activities, accidents in the outdoors and rustic
Camp Consent & Release
January 2017
Page 1 of 2
facilities, adverse weather conditions, and injuries and illness as a result of food-borne illnesses and allergic reactions. In addition, I understand that there may be other risks inherent in Camp activities of which I may not
be presently aware.
By signing this Parental Consent and Release of Liability, I warrant that Camper is fully capable of safely participating in all Camp activities, and I expressly assume all risks of Camper’s participation, whether such risks are
known or unknown to me at this time. I further generally release Red River Valley Honors Camp and its directors, officers, employees, volunteers, and agents, and other campers at the Camp, from any and all claims that I
or Camper may have against any of them as a result of property damage or personal injury, illness or death of
Camper as a result of participation in Camp activities, whether on or off Camp grounds. I agree that this release
includes the ordinary, special and inherent risks described above, and other risks that I may not foresee or be
aware of at this time. This Release of Liability is given on behalf of myself, Camper, and the heirs, family, estate,
administrators, executors, personal representatives and assigns of me and Camper.
Other Releases and Acknowledgements
I understand that, while Camper is participating in Camp activities, photographs, film, audio recordings and
videotape of Camper may be taken for use in brochures, videos, releases to the press, and various Red River Valley Honors Camp publications and other work product. I do hereby irrevocably grant Red River Valley Honors
Camp permission to record, display and/or reproduce my child’s name, likeness and voice on audio and/or video tape, film or other media, to edit and otherwise modify such media at its discretion, to incorporate the media
into any work product, and to use or authorize the use of such media or any portion thereof in any manner or
media or by any means, methods or technologies now known or hereafter to be known.
I understand that Red River Valley Honors Camp does not provide transportation to or from the Honors Camp
program and do hereby take responsibility for either providing or arranging for transportation of Camper, and
for ensuring that Camper will arrive and depart by the scheduled dates and times.
I will ensure Camper only brings clothing that adheres to the Camp Dress Code or similar policy included as
part of this package or to be sent in the acceptance package. If Camper fails to abide by established rules,
standards of conduct and/or Camp Dress Code, Red River Valley Honors Camp staff reserve the right to send
Camper home. If it becomes necessary to send Camper home, I hereby agree to provide transportation or to
make travel arrangements for Camper and to assume the cost of these expenses.
To the extent any provision of this document is found to be unenforceable, such provision shall be deemed severable and shall not affect the enforceability of any other portion of this document, and shall be reformed to be
in compliance with the law and construed to most nearly reflect the intent of the parties.
I represent and warrant that I am a parent or legal guardian of the Camper named above and have the full power and authority to enter into this Parental Consent and Release of Liability on behalf of the Camper. By signing
below, I acknowledge that this document has been read and understood by me, and also represent that all information provided is accurate. Each legally responsible parent/guardian is required to sign below.
_____________________________________________________
1st Parent or Guardian signature – required
______________________________________________________
2nd Parent or Guardian signature - required
_____________________________________________________
Name Printed
______________________________________________________
Name Printed
_____________________________________________________
Date Signed
______________________________________________________
Date Signed
_____________________________________________________
Daytime Phone
______________________________________________________
Daytime Phone
_____________________________________________________
Evening Phone
______________________________________________________
Other Phone
_____________________________________________________
________________________________________________
Witness Signature (Required, age 21 or older and not a relative)
Camp Consent & Release
January 2017
Date Signed
Page 2 of 2
Optional Theme T-shirt
Note: If you are a Super Senior (just graduated from high school) you
need to order this specially designed “theme” t-shirt!
Each year we choose a camp theme, design a theme logo, and offer an oponal
“theme” t-shirt at addional cost. This is in addion to the complimentary
“team” t-shirt (JH, HS/R, B, G, Y) everyone already receives. Our theme this year
is “OUR AMAZING GOD” and Jeremiah 24:7, “I will give them a heart to know me,
that I am the LORD. They will be my people, and I will be their God, for they will
return to me with all their heart” is the key verse. (See below)
The size you order is the size we will give you (no exchanges unless you find
someone to trade with) and the price is $10 if paid (postmarked) by May 1 or is
$13 if paid a>er May 1. If you order a “theme” t-shirt, please add this amount to
your payment for your applicaon/registraon and complete and return the following informaon:
Name:________________________________________
T-Shirt Size (circle one) : Youth(14-16)
January 2017
Adult: S M L XL XXL