2024 Preteen Camp

July 23rd - July 27th

For preteens who've completed 4th, 5th, or 6th grade

Pleasant Valley Ranch

4023 State Route 603

Perrysville, Ohio

Camper Information

Registration Options

Early Bird ($195.00)
Registration prior to Thursday June 20th

Camper Name

Nickname

Gender

Male
Female

Date of Birth

Last Grade Completed

Parent or Guardian Name

Please provide parent Facebook Profile name so we are able to add you to our FB group.

Mobile Phone Number

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Parent or Guardian Name

Please provide parent Facebook Profile name so we are able to add you to our FB group.

Mobile Phone Number

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Home Phone Number

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Parent Email

Address

Local Church

Bunkie Request (Not Guaranteed)

If Camper is NOT being picked up by parent, guardian, or church please indicate who is authorized to pick up your child (Name and Phone #)

Does this camper currently have a custody agreement or do not release agreement in place?

Yes
If YES, please send a copy of said agreement. This is to ensure the safety and well being of the child. Any questions or concerns may be directed to the camp director.
No

Camper Medical Information

Medications: Please list any and all medications to be administered at camp

Medicines

Yes my child has medicine
No my child does not have medicine

1. Name of Medication

2 Name of Medication

3. Name of Medication

All medication MUST be in the original container and will not be administered otherwise.

All medication will be documented and administered by a state-licensed Registered Nurse.

All medications MUST NOT be packed in the child's bag and should be in a clear ziplock bag and given to the nurse at registration.

Allergies: Please indicate all known allergies and suggested treatment/necessary medications (epi-pen, Benadryl, ect.)

Allergies

Yes my child has allergies
No my child does not have any allergies

Recent Injury/Serious Illness/ Or any other Physical/ Personal Limitations (brief explanation)

Insurance Information

Insurance Carrier

Group and/or Policy #

Name of Policy Holder

Emergency Contracts (in event parent/guardian can not be reached)

1. Emergency Contact Name

Relationship

Phone Number

2. Emergency Contact Name

Relationship

Phone Number

I hereby give consent for the camp nurse to dispense over the counter medication such as, but not limited to, Acetaminophen, Ibuprofen, ect to the camper named above. I also hereby authorized the release of all medical information to an attending physician in case of an emergency. In the event that I cannot be reached immediately, I hereby give permission to the camp staff to secure proper emergency medical care for illness or injury incurred during camp for the camper named above.

Med Care Release ------Parent/Guardian Name

Date

Media Release

I hereby grant Permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tame without payment or any other consideration. I understand that my image may be edited copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.

Photographic, audio or video recordings may be used for the following purposes:

conference presentations
educational presentations or courses
informational presentations
promotional videos

Media Release -------Parent/Guardian

Date