2026 Middle School Ministry Summer Camp

Student Name

Student Address

Student Grade entering Fall 2026

Parent(s) Name

Parent(s) Phone

Parent Email

Additional Emergency Contact (Name & Phone)

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

Understanding that the appropriate measures will be taken to contact parent listed and the additional emergency contact, as parent named above (if student under 18) or student (if 18+), 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 named 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

On behalf of the named participant, I give permission for the camp nurse, Shiloh Pastors &/or Shiloh leaders to give non-prescription medication as deemed necessary. Medications may be name brand or generic. Please select any that apply.

Acetaminophen (generic Tylonol) Ibuprofen (generic Motrin, Advil) Antacid (Maalox, Tums) Hydrocortisone Cream, Benadryl Cream, Neosporin Ointment Travel Nausea Medicine (Dramamine, Bonnine) Any/all of these above as needed Other (directly email Pastor Levi) None

Payment

By providing my name, I confirm consent regarding this registration and releases above.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 6-11, 2026

2026 Middle School Summer Camp Registration!!

Join us for a week of summer camp in the San Bernardino Mountains at Alpine Retreat and Camp in Blue Jay, CA. This week will provide a space to engage God’s Word through teaching and small group discussion, enter into worship through prayer and singing, and fellowship with one another as we enjoy the beautiful outdoors. There'll be awesome recreational activities such as zip lining, a high ropes course, a lake day, and more! Students will have the opportunity to connect with each other and their leaders as they step out of their regular routines and enter into a time of refreshment in the Lord.

The cost of camp is $175. Registration will close on Sunday, May 24 at 11:59 PM. Students will need to bring money for their meal on the way to camp and on the way home, as well as for the coffee shop/snack bar at camp. Upon registration, look out for additional emails with important details, such as waivers, packing list, etc.

We will leave for camp from Shiloh on Saturday, June 6 and return to Shiloh on Thursday, June 11.

2026 Middle School Ministry Summer Camp

Description

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