Δ Camper Information:Camper's Name(Required) First Last Camper's Home Address(Required) 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Camper's Phone(Required)Camper's Email(Required) Camper's Gender(Required)MaleFemaleNon-BinaryOtherIf "Other" was selected for the camper's gender, please specify here.(Required)Camper's Date of Birth(Required) Month Day Year Grade Camper Completed by Summer(Required)6789101112Camper's Age at the Time of Camp(Required)111213141516171819Camper's T-shirt Size(Required)Extra SmallSmallMediumLargeExtra LargeParent/Guardian InformationHow Many Parents/Guardians does the Camper have?(Required) One Two Parent/Guardian Name(Required) First Last Parents/Guardians Phone(Required)Parents/Guardians Email(Required) Parents/Guardians Address(Required) 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parents/Guardians Name 2(Required) First Last Parents/Guardians Phone 2(Required)Parents/Guardians Email 2(Required) Parents/Guardians Address 2(Required) 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Information and More.Congregation Camper Attends(Required)Boise, Red Rock Christian ChurchBoise, Pacific Outreach Christian ChurchCaldwell, Treasure Valley Christian ChurchHomedale, Christian ChurchMeridian, New Hope Christian ChurchMountain Home, Christian Baptist ChurchNapa, First Christian ChurchIone Community Church (UCC and Disciples of Christ)John Day, First Christian ChurchLa Grande, First Christian ChurchOntario, First Christian ChurchPendleton, First Christian ChurchCentennial Christian ChurchChukienu Family Church – VancouverFirst Christian Church – PortlandHood River Valley Christian ChurchMidway Christian ChurchNueva Vida (Gresham)Murray Hills Christian ChurchPacific Islands Family Church – PortlandPacific Islands Family Church – VancouverPeniel Ministries – PortlandRio de DiosThe ViewAlbany, First Christian ChurchCorvallis, First Christian ChurchDallas, First Christian ChurchKeizer Christian ChurchKeizer, Iglesia Christana Jehovah NisiLebanon, First Christian ChurchMcMinnville, First Christian ChurchSalem, Chuukese Family Christian ChurchSalem, First Christian ChurchSilverton, First Christian ChurchEugene, Allison Park Christian ChurchEugene, First Christian ChurchEugene, Glenwood Christian ChurchGrants Pass, First Christian ChurchJunction City, First Christian ChurchMedford, First Christian ChurchNorth Bend, First Christian ChurchSpringfield, First Christian ChurchSpringfield, Northwood Christian ChurchOtherIf you selected Other please give us the name of your congregation(Required)Physician's Name(Required) First Physician's Phone(Required)Dentist's Name(Required) First Dentist's Phone(Required)Health Insurance Company(Required)Insurance ID Number(Required)Group number if applicableSubscriber name and relationship to camper(Required)Emergency Contact (Other than Parents/Guardians) Name(Required) First Last Emergency Contact (Other than Parents/Guardians) Phone(Required)Emergency Contact (Other than Parents/Guardians) Relationship(Required)Emergency Contact (Other than Parents/Guardians) Name 2(Required) First Last Emergency Contact (Other than Parents/Guardians) Phone 2(Required)Emergency Contact (Other than Parents/Guardians) Relationship 2(Required)Allergies (Select all that Apply)(Required) None Asthma Ivy/Oak/Sumac Poisoning Hay Fever Bee/wasp sting Penicillin Food Other If you Selected "Food" or "Other" Please Explain(Required)Immunizations(Required) Measles Mumps Rubella Polio What was the Date of Camper's Most Recent Tetanus Toxoid Shot?(Required) Month Day Year Medical History (Check all Applicable)(Required) None Diabetes Kidney Disease or Trouble Heart Murmur or Trouble Epilepsy Fainting Stomach Upsets Eating Disorder Rheumatic Fever Frequent Colds Frequent Sore Throat Tonsillitis Strep Throat Bronchitis Sinusitis Ear Infections Other If You Checked Anything in the "Medical History" List, Please Explain Any Information that will be Helpful for the Staff to Know.(Required)Other Information (Check all that Apply)(Required) None Attention Deficit Disorder Contacts Glasses Motion Sickness Learning Disability Hyperactivity Sleep Walking Athlete’s Food Bed Wetting Convulsions Constipation Particular Fears Anxiety Depression Other If you Checked Anything in the "Other Information" List, Please Explain Any Information that will be Helpful for the Staff to Know.(Required)List All Medications and Dosages You Anticipate Taking at Camp, Including Over-The-Counter Medicines.(Required)Is the Camper Currently Under the Care of a Physician or Counselor?(Required) Yes No Please Explain Further Why the Camper is Currently Under the Care of a Physician or Counselor.(Required)Are there Any Life Circumstances or Behavioral Issues Involving You that may be Helpful for the Staff to Know?(Required)Are there Any Specific Activities in which Participation Should be Encouraged?(Required)Are there Certain Situations or Group Dynamics that could Lead to Behavioral Challenges?(Required)Are there Any Special Dietary Needs or Restrictions? If Yes, Please Explain.(Required)Is there any Other Information that would be Helpful for the Staff to Know?(Required)ConsentCamp Staff often times take photos and videos of youth during camp. When these pictures are used through social media, print publications, fliers and brochures, this is done without names or home congregations of the youth/adults listed. Sometimes other campers may post the pictures accompanied by their first and last name, and information regarding the student’s participation in a program or activity. We cannot fully control the use of individual campers posting pictures after the camp. Please indicate your preference.Please Choose if you Give Consent or Not.(Required) I have read the statement and give my permission for pictures of my child/teen to be used in publicity/news photos without names. I have read the statement and DO NOT give my permission for pictures of my child/teen to be used in publicity/news photos without names. Parental Consent:I give permission for the youth named in this registration to attend camp and to participate in all the scheduled activities of the camp which may be on or off the event site. Recognizing that the staff of this event will do everything possible to provide for the safety and supervision of the attendees, I release the volunteers and paid staff of Christian Church in Oregon & SW Idaho from liability regarding any incident which may arise during this event. In the event of an emergency, I give the leaders and staff permission to obtain whatever medical attention is necessary (including anesthesia and medical transport) for the health and well-being of my child. By signing my name below I am signing my agreement to the “Parental Consent” statement above.Signed Name(Required)Sign your name here to agree to Parental Consent. First Last Camp 2024 Behavior Covenant In a spirit of trust and love, promising to treat each other respectfully, we will: Listen without judgment Value one another’s ideas and feelings and needs Speak honestly and directly Foster growth and understanding among us, so that our actions and intentions embody God’s vision. Follow all safety regulations of the camp facility Participate in all activities to the best of my ability Help maintain a clean and safe environment by picking up after activities, cleaning our cabin spaces, and engaging in OTS Be open to diverse ideas, feelings and needs; welcome others fully. Practice honest and kind communication to solve conflict. Ask for help when overwhelmed or if you see someone in danger. Pay attention to our own needs – physical, emotional, and spiritual. Use the buddy system to create a safe community for all. Share our individual gifts to create a more powerful camp experience for all. Each youth will be asked to read and sign a behavioral covenant when they arrive at camp. This covenant will be emailed ahead of time to the email address you have provided. Do you agree to review the covenant with your youth and understand that they are required to agree to the covenant by signature upon their arrival at camp?(Required) Yes Cost The cost of camp this year is $400 per camper. Many congregations assist with these payments. If you are in need of financial assistance there are also scholarship funds available. Please let Alicia Speidel know if that is the case. Camper fee(Required) Price: Total Credit CardFeed Required: To use the Stripe field, please create a Stripe feed for this form.
