SD Jr. Camp - August 4-6, 2025

Name of Student

DOB

Age

Sex

Is this the first time away from home overnight?

Yes No

1st Parent/Guardian

Phone

This address will receive a confirmation email

2nd Parent/Guardian

Phone

This address will receive a confirmation email

Emergency Contact

Phone

This address will receive a confirmation email

Authorized Pick Up Person

Home Church

Pastor's Name: By typing your pastor's name, it is understood that you have obtained permission from your pastor to attend Jr. Youth Camp.

Does the camper have any allergies, chronic illness, medical conditions, food restrictions, or special concerns?

Yes No

If yes, please describe

Please list any medications the camper will be taking while at camp.

Please relate any additional information you would like to share about your camper.

Jr. Camp T-shirts are: $15 for students, $25 for adults. Would you like to order a shirt?

Yes No

T-shirt size(s)

I hereby give my approval for my child’s participation in any and all activities prepared by South Dakota Children’s Ministries during the selected camp. In exchange for the acceptance of said child’s candidacy by South Dakota Children’s Ministries, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless South Dakota Children’s Ministries and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against South Dakota Children’s Ministries, including all affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities. Please type your signature below.

As parent/guardian of I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to South Dakota Children’s Ministries and its affiliates including directors, counselors, and camp staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. Please type your signature below.

Camper Name

Registration Date

Youth T-Shirts 1-$15 2-$30 3-$45 4-$60

Adult T-Shirts 1-$25 2-$50 3-$75 4-$100

Payment: Registration is $75. If you are ordering t-shirts, please click the button for the type (youth or adult), and the quantity of shirts. Determine your total for shirts, then add $75. Select the 'custom' option from the payment dropdown, enter your total purchase amount and process your complete payment. The registration, shirt order, and amount paid must match for shirts to be ordered. Thank you!

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

SD Jr. Camp - August 4-6, 2025

Description

Please Fix the Following