2025 High School Winter Camp

Student Name

Student Email

This address will receive a confirmation email

Student Phone

Student T-Shirt Size

Small Medium Large X-Large XX-Large

Parent(s) Name

Parent(s) Phone

Address

Emergency Contact (Name & Phone)

Medical Insurance Information (primary person for coverage, Insurance Company, Policy Number)

Please list any allergies (if none, put none)

Please list any food restrictions/special dietary needs (additional form from Lost Canyon will need to be completed)

Please indicate if student will bring any medications (additional form will be needed to be completed)

Understanding that the appropriate measures will be taken to contact me and the emergency contact, as parent named above, I/We give our consent to the adult leaders of this trip to provide any necessary decisions regarding the above student's health and/or life. I/We also give consent to any licensed medical professional to take appropriate measures to preserve the health and/or life of the above named student.

Yes No

On behalf of the named participant, I agree to hold harmless Shiloh Community Church and the leaders of this trip for any liability sustained due to the participant's negligence (intentional or unintentional), including expenses incurred as a result. I agree to reimburse Shiloh Community Church, and/or the leaders of this trip any financial expenses incurred due to the participant's negligence (intentional or unintentional).

Yes No

On behalf of the name participant, I agree to give Shiloh Community Church and the leaders of this trip the right to use the participant's name (or functional name), picture, portrait, or photograph in all forms and media in all manners, including composite or distorted representations, for advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection with this activity.

Yes No

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

January 17-20, 2020

Winter Camp 2025 will once again be up at Lost Canyon Camp in Williams, AZ along with other churches from around the Phoenix, Payson and Prescott areas. This weekend will be filled with worship, teaching, fellowship, games, laughter, and fun.

January 17-20, 2025 are the dates, and cost is $290, which covers transportation, food and lodging at camp (other than coffee or snacks), and food on the way home. We will stop for dinner on the way up to camp...which student is responsible for buying. Pastor Kevin will supply a list of what to bring (and not to bring) to camp.

We'll leave Shiloh at 3:30pm on Friday, January 17 and return approximately 3pm on Monday, January 20.

2025 High School Winter Camp

Description

Please Fix the Following