2010WDYOUTHSENIORCAMPCAMPERAPPLICATION

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NAME_______________________________________________AGE______BIRTHDATE_____________SEX_______
ADDRESS________________________________________________________CITY____________________________
ZIPCODE____________________PHONE______________________________________________________________
EMAILADDRESS__________________________________________________________________________________
Underdoctorscareatpresent:Yes:_____No:_____
For:_____________________________________________________________________________________________
Itakemedicineatpresent:Yes:_____No:_____InthepastthreemonthsIhavebeenill:Yes:_____No:_____

CHECKANYBELOWTHATAPPLYTOYOU
DiabeticYes__No__CangoinwaterYes__No__CanRunYes__No__TakeThyroidMedicationYes__No__
HeartDiseaseYes__No__KidneyDiseaseYes__No__TakeInsulinYes__No__TakeAsthmaDrugsYes__No__
Allergies:Yes__No__toEggsYes__No__TetanusYes__No__ChocolateYes__No__PenicillinYes__No__
EpilepsyYes__No__Other:_________________________________________________________________

Thiscampermayparticipateinallcampactivities.Thiscampermayreceiveemergencymedicaltreatment.Campprincipalhasmypermissionto
signforMedicalTreatment.Iaffirmtheaboveinformationtobetrue,andthiscampermayparticipateinallcampactivities.Iunderstandthe
LiabilityReleaseForm.

_______________________________ _______________________________
PARENT/GAURDIANSIGNATURE CAMPERSIGNATURE

ThiscamperisrecommendedtoattendSeniorYouthCamp.

_______________________________ _______________________________
PASTORSNAME PASTORSSIGNATURE

HowlonghasthecamperattendedChurch?____________SundaySchoolOnly?___________
HavetheHolyGhost?_________
Itismandatorythatallcampershavetheirpastorsrecommendationstoattendandthepastorssignatureontheregistrationform.Pastor:to
fulfillourpurposeanddesireofthiscamp,itismandatorythatallpastorssendingcampersmustgothroughthedresscoderulescompletelywith
prospectivecamperspriortotheirattendanceatcamp,ifanyquestionspleasecontactthecampprincipal.

___________________________________________________________________________________________________

DONOTWRITEINTHISSPACECAMPFEE$_________________DEPOSIT$_________________BALANCE$_________________

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WESTERNDISTRICTOFTHEUNITEDPENTECOSTALCHURCH
MEDICALTREATMENTCONSENTANDLIABILITYRELEASEFORM
CALIFORNIACIVILCODESECTION25.8

ItismydesirethatIormychild/ward,participateintheactivitiesofSeniorYouthCamptherefore:

I,theundersignedparent/guardianof_____________________________(CampersName),doherebyauthorizetheadultsponsorof
SeniorYouthCamporanyresponsibleadultpersonbearingthiswrittenauthorization,intothosesaidcaretheabovementioned
minorchildhasbeenentrusted,toobtainpropermedicalcarefromalicensedmedicalordentaldoctororfacility.Themedical/dental
careistoinclude,butnotlimitedto,anyxrayexamination,anesthetic,medicalorsurgicaldiagnosisortreatmentandhospitalcare
toberenderedtosaidminorunderthegeneralorspecialsupervisionandupontheadviceofalicensedmedicaldoctorordentist.

Itisunderstoodthatthisauthorizationisgiveninadviceofanyspecificdiagnosis,treatmentorhospitalcarebeingrequired,butis
giventoprovideauthorityandpoweronthepartofsaidadultpersontogivespecificconsenttoanyandalldiagnosis,treatmentor
hospitalcarewhichtheaforementionedphysicianordentistintheexerciseofhisjudgmentmaydeemadvisable.Thisauthorization
shallincludetransportationtoreceivethemedicalordentalcare.

FINANCIALRESPOSIBILITY
Intheeventofinjurytomyself,ormychild/wardIagreethatI/Weandmyhealthcareinsurershallbefinanciallyresponsibleforanymedical
treatmentrequiredbymyself,orchild/wardasaresultofanyinjuryorillnesssufferedduringhis/herparticipationinanySeniorYouthCamprelated
activities.

RISK
Iamawarethattheseactivitiesmayinvolvesomehazards.IhaveconsideredtheserisksandIstillwishmyself,ormychild/wardtoparticipate.
Furthermore,IagreenottobringlegalactionagainsttheWesternDistrictoftheU.P.C.,stafforsponsorsasaresultofanyinjuriessufferedinthe
courseofhis/herparticipation.

DISPUTE
IntheeventadisputearisesbetweenmyselfandTheWesternDistrictoftheU.P.C.concerninginjuriestomychild/ward,thenIagreethataChristian
arbitratoracceptabletobothsidesshallresolvethedispute.Thecostofthearbitratoristobesharedequallybytheparties.Allapplicablestatutesof
limitationshallapplyandarbitrationmustberequestedwithintheappropriateperiodinordertoreservearighttorecovery.

TERMOFAGREEMENT
Thisauthorizationwillremainineffectwhilemyself,ortheminoraboveisinroutetoorfromorinvolvedorparticipatinginanyprogramoractivity
authorizedbytheWesternDistrictoftheU.P.C.,unlessrevokedbytheundersignedinwritinganddeliveredtotheagentoftheWesternDistrictof
theU.P.C.

___________________________________________________________________________________________________
Date Signature Relationship

___________________________________________________________________________________________________
Address City State Zip

___________________________________________________________________________________________________
Phone(Day) Phone(Night) MedicalIns.Co.

___________________________________________________________________________________________________
DoctorsName DoctorsPhone GroupCert.OrI.D.

SpecialHealthInstructions:

___________________________________________________________________________________________________
___________________________________________________________________________________________________
CONCERNINGOURAPPEARANCE
Pleaseretainthispageforyourreference.Itdoesnotneedtobesubmittedwithyourapplicationandreleaseform.

TOTHESTAFF:ALLTHESTAFFMEMBERSWILL:
1. Bebornagainandchurchmembersingood bewornsoastocovertheirknees.Necklineswillbe
standing. modestanddecent.Tightfittingclothesshallnotbe
2. BeresponsibleleaderswithYoungpeople. worn.Nomakeuporjewelrywillbeworn.Noskirts
3. WillacceptalltheguidelinessetbytheYouthCamp ordresseswithslitsabovetheknees.Also,in
Committee. keepingwiththeunityofthedistrict,weaskthat
4. DRESSCODE:AllStaffMemberswillbewearing therebenomustachesorbeards.
sleevestotheelbow.Thedressesoftheladieswill

GENERALCAMPRULES
1. Nooneistobringmatches,fireworks,knives,
radios,oranydevicethatwouldbedangerousor
disruptivetothecamp.
2. Allcamperscommutingtoandfromthecampare
undertheresponsibilityoftheparentsand
guardian.
3. Campersarenotallowedtoleavethegroundsafter
theyregisterwithcampdirectororheadcounselor.
4. Allcampersareexpectedtobepromptatallmeals
andmeetingsunlessexcusedbythecampdirector
orheadcounselor.
5. Allcampersarerequiredtoattendallclasses,
chapel,recreationalactivities,andeveningservices.
6. Boysarenotpermittedtoentertheareaofthe
girlsdorms,andgirlsarenotpermittedtoenterthe
areaoftheboysdorm.Thisalsomeanstheyshould
notbeintheareaoftheothersbathsorshowers.
7. Allathleticequipment(personalorcamp)and
facilitiesareundercontroloftherecreationdirector
andmayonlybeusedasinstructedbythedirector.
8. Everystaffmemberandcampermustbe
responsibleforhisorherownbeddingandpersonal
property.Allshouldgiverespecttothecamp
facilitiesandpropertyofothers.
9. Anycamperdefacinganypropertyortampering
withpropertyofanothermustpaythedamage
incurredandcanbeexpelledimmediately.
10. Absolutequietandreverenceisexpectedfrom
everycamperduringchapel,classes,andservices.
Enterthesesessionswithaspiritofreverence,and
leaveasorderlyandquietlyapossible.These
servicesshouldbehighmomentsofinspirationand
encouragement.
11. Staffandcampersarerequiredtostayintheir
dormseachnight.Nolightsornoise,whichdisturbs
others,willbepermitted.
12. Allcampersaretoremainintheirassignedareasof
sleeping.Noswitchingispermittedwithoutconsent
ofcounselorsandtheheadcounselor.
13. Intheinterestofprotectingtheprivacyofeach
camper,imagetechnology(stillandvideo)shallnot
beusedassuchinbathrooms,showers,anddorm
areas.Failuretocomplywiththispolicymayresult
intheconfiscationofsaiddevicestilltheendof
campanddeletionofthecontentofsaiddevices.

WESTERNDISTRICTSENIORYOUTHCAMPGUIDELINES
CAMPPRINCIPALTERRYDWORACZYKSantaMariaFairgroundsSantaMaria,CAAUGUST712,2010.CHECKINTIMESaturday,
August7,2010at10:00a.m.forpreregisteredcampers11:00a.m.fornonregisteredcampers.CHECKOUTTIMEThursday,August
12th11:30a.m.12:00p.m.ImmediatelyfollowingtheannualSportsAwardandInspirationalDevotion.NOCAMPERWILLBE
PERMITTEDTOCHECKOUTBEFORETHISTIME.AGES1425.Therewillbenoexceptionstothisagespan.Agewillbedeterminedby
thecampersageduringthemonthofAugust.

THISCAMPISFORTHEFELLOWSHIPANDDEVELOPMENTOFSINGLEYOUNGPEOPLEWHOARENOTPARENTSANDWHOHAVE
NEVERBEENMARRIED.CAMPFEEIS$145.00(PreRegistered)$160.00FeeforthosewhodonotPreRegister(Therewillbeno
prorateoffeeforthoseattendingapartialweek.)Mail(NonRefundable)RegistrationFeeof$40.00DepositAndApplicationbefore
July15,2010toPreRegisterSendto:WDUPCYOUTHDIVISIONSENIORCAMPP.O.Box547,Bakersfield,CA93302

*Becauseofinsuranceandothercontrollingmatters,therewillnotbeanyvisitors(dayornight)permittedonthegroundsexcept
forministersandtheirspouses.Nocamperwillbepermittedtostayoffcampus.

OURDESIRE:ItisthedesireoftheYouthLeadersoftheWesternDistrictthatourYouthsetagoodexampleofthebelieveratall
times,athome,atschool,inourcommunities,atchurchandatourYouthCamps.OURPURPOSE:Itisourpurposetoprovidea
balancedweekthatwillbetrulyrememberedbyallasenrichmenttotheirChristianlife.Becauseofthis,afullweekisplannedfor
youofSpiritualenrichmentphysicalrecreations.socialactivityandfellowship.THEREFORE,WEASKALLCAMPERSANDSTAFF
TODRESSINAGODLYMANNER.WEARETRYINGTOPRESENTACHRISTLIKECAMPATMOSPHERE.