Summer Camp Registration Form Select Camp Attending:* Elementary (6/21-24) Youth (6/21-25) Family (6/24-25) Camper’s Preferred Name* First Last Camper’s Home Church (if attending with Presbyterian friend, indicate friend’s church)* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent/ Guardian(s) Name:* First Last Best Guardian Phone:*Parent email:* Camper Date of Birth:* Gender* Male Female Grade completed by camp date:* T-Shirt Size*Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeXLXXLChoice of cabin mate (please make ONLY ONE):*(Only the first name listed can be honored) Person(s) picking up camper from camp:* EXPECTATIONS:Parents or guardians should understand that the Adult Representatives of the Savannah Presbytery Summer Camp are responsible for maintaining order and administering discipline during the duration of the event in which your camper is participating. Should a camper, in the view of the Adult Representatives, become a chronic disciplinary problem, the parent or guardian will be notified and the camper will be sent home at the guardian’s expense. Parents are liable for any property damage caused by their camper. I give permission for the Presbytery to use my child’s photo in promotional materials and on the Savannah Presbytery website. I hereby release Savannah Presbytery, its staff and adult representatives from responsibility and liability for any injury or illness that my child may sustain during an event. In the event of an emergency, I authorize an adult representative of Savannah Presbytery, as agent for me, to consent to any x-ray exam, medical, dental or surgical diagnosis or treatment and hospital care advised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where services are rendered, either at a doctor’s office or in any hospital. In the event of an emergency or major concern, parents will be contacted as soon as possible.Parent Signature*Emergency Contacts if parent cannot be reached:Name of emergency contacts if parent cannot be reached:* First Last Phone*Relationship* Name of emergency contacts if parent cannot be reached:* First Last Phone*Relationship* Is the camper in good health and able to participate in all normal activities?* Yes No If not, please list any of camper’s chronic medical conditions, health concerns, and serious allergies .*Please also list any medications and write out specific instructions (amount and time to be taken)*Has there been any family crisis in the past year (e.g. moving, death, separation, etc?) Yes No If yes, please explainMy child may be provided topical therapies, an antacid, acetaminophen or ibuprofen if necessary.*SignatureDate of last tetanus shot:* Family Physician:* Physician Phone number:*Name and policy number of family’s insurance:* Member’s Name:* PricingYouth CampRising 7th Graders - Graduated Seniors June 21-25 (M-F, 4 nights/5 days) Early Bird After April 19th Total Price: $0.00 Elementary Camp(Rising 3rd graders - 6th graders) June 21-24 (M–TH, 3 nights/4 days) Early Bird After April 19th Total Price: $0.00 Partial Waiver & Release of Liability & Parental ConsentIn consideration of New Ebenezer furnishing services and/or equipment to enable me/my child to participate in canoeing, I agree as follows: I fully understand and acknowledge that outdoor recreational activities have: (a) inherent risks, dangers and hazards and such exists in my use of a canoe and my participation in canoeing; (b) my/my child’s participation in such activities and/ or use of such equipment may result in injury or illness; (c) these risks and dangers may be caused by the negligence of the participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. Risks and dangers may arise from foreseeable and unforeseeable causes including risks, hazards and dangers that are integral to recreational activities that take place in a wilderness, outdoor or recreational environment; and (d) by my/my child’s participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or dangers. I hereby agree and consent to my/my child’s participation in canoeing provided by or on behalf of New Ebenezer Family Retreat and Conference Center for the age group in question. I, on behalf of myself/my child, and my personal representative, hereby waive, release and discharge New Ebenezer, its agents and employees, of any claim whatsoever that is not the direct result of active, foreseeable negligence on the part of New Ebenezer and its respective agents and employees. I further waive, release and discharge New Ebenezer from any claim whatsoever on account of first aid, treatment or service rendered to me/my child as a result of my/my child’s participation in canoeing. I have read the above partial waiver and release of liability and parental consent and by signing it agree that it is my express intent to exempt and relieve New Ebenezer from liability for personal injury, property damage, or wrongful death other than such claims that arise as the direct result of active, foreseeable negligence.Name of Participant:* First Last Age if minor:*Signature (if 18 years of age or older):Signature of Parent/Guardian (if less than 18 years of age):Date* MM slash DD slash YYYY Family Camp(Rising 2nd graders and younger) June 24-25 (TH-F, 1 night/ 2 days) Cost for one child plus one guardian Additional family members(Rising 2nd graders and younger) June 24-25 (TH-F, 1 night/ 2 days) Price: $40.80 Quantity: Total Price: $0.00 Please list all family members that will be attending Family CampNote: each member needs to fill out a form and submit it.CommentsThis field is for validation purposes and should be left unchanged.