Camp Refuel Registration - Light the Night Ministries

Camper information

Camper Name *

First

Last

Preferred Name for Name Tag

Gender *

Male
Female

School grade level (Fall 2022) *

T-shirt size

Camper Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Camper Phone *

Camper Email *

Email

Confirm Email

Church or youth group affiliation

Has the camper been camping before? *

Yes
No

Preferred cabinmate

Emergency Contact Information

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.

Relationship *

Parent
Sibling
Relative
Friend

Contact Name *

First

Last

Contact Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Phone *

Contact Email *

Email

Confirm Email

Questions or Comments

Medical Information

General Health *

Does the camper have any known allergies? *

Yes
No

Allergies AND medications required to treat

Does the camper have any special dietary needs? *

Yes
No

Diet requirements

Does the camper require any medication while at camp? *

Yes
No

Medications required

Can the camper fully participate in all activities? *

Yes
No

Activity Restrictions

Tetanus vaccine date *

Polio vaccine date *

MMR vaccine date *

DPT series date *

Doctor Name *

Doctor Phone *

Media Release

I hereby grant the Light the Night Ministries, its directors, officers, employees, agents, and designers (collectively “LTN”) non-revocable permission to capture my image and likeness in videotapes, motion pictures, recordings, or any other media (collectively “Images”). I acknowledge that LTN will own such Images and further grant the LTN permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to LTN business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the LTN prior to its use. I forever release and hold the LTN harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to use of the Images, including without limitation, claims for invasion of privacy rights or publicity.

Media Consent *

I agree to the media release conditions
I do NOT agree to the media release conditions

Payment

Payment Options *

Pay Now - $ 25.00
Send a check - $ 0.00
Paid by church - $ 0.00

Check payment

Please mail your check to: Light the Night 1412 Valley Road South Hill, VA 23970

Signature *

I agree for my child listed on this form to attend the Camp Refuel weekend and attest to the accuracy of all information by my signature in the box above. I also authorize Camp Willow Springs and Light the Night Ministries to act in their best judgment in any emergency requiring medical attention. I release Camp Willow Springs and Light the Night Ministries from liability for any injury or illness incurred at camp.