First Name :

Last Name:

Date of Birth mm/dd/yyyy (birth years from 2013 to 2017):

Gender (Required): Male Female

Shirt Size (Required):
Select a Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large

Address:

City:

State/Province:

Postal Code:

Country:

Cabinmate (optional - please provide full name):
If possible, I would like the below person to be my cabinmate (optional). He/She must be the same age and must have requested you as well. Requests outside of this guideline may not be honored.

Parent/Guardian Information

First:

Last:

Email (this is where your registration information will be sent to):

Cell Phone (if you don't have a cell phone please provide the best number to reach you in the cell phone field):

Home Phone:

Work Phone:

Relationship:
Required Father Mother Legal Guardian Other

If you selected 'other' above please provide details.

Other Relationship:

Saturday Pick-up Person

First Name:

Last Name:

Cell Phone:

Church Information

Church Name:

City:

State/Province:

Pastor's Name:

Group Leader:

Insurance Provider Information

Provider Name:

Policy Number:

Group Number:

A copy of the applicant's insurance card and a copy of the applicant's immunization records may be sent to us by mail to: 333 Cedine Camp Road, Spring City, TN 37381, or emailed to us at camp@cedine.org. Please include your child's full name and the name and dates of the camp they are attending.

Health Information

Medical Conditions (A Response is Required)

Are there any health or behavioral conditions, or other medical concerns that Cedine should be aware of for your child?

None Known

Asthma

Other (describe below):

Allergies (A Response is Required)

None Known Bee Stings Nuts Penicillin Aspirin Hay Fever Sulfa

Other Allergies or Details:

Medications

Any and all medications sent with a camper must be in their original containers, or they will not be administered. List below any and all medications, along with their dosages and administration schedule.

In the box below indicate any special needs, comments or requests.

Cell Phone / Electronics Policy Agreement

In this technology age it is difficult for you and your child to not be in contact via cell phone. Camp is a unique environment. We are trying to help youth develop life skills at camp including independence and self-reliance. Oftentimes homesickness, which is a normal part of a week at camp, can be worsened by talking to mom and dad. We respect and appreciate the wonderful relationship youth and families have, but if your campers are to enjoy the camp fully they must be able to develop this independence.

Campers are not allowed to bring cell phones or any other electronic devices to camp. If a cell phone or other electronics are brought with a camper they must be turned into the Camp Office upon arrival. Campers do not have access to camp phones. If there is an emergency or we are concerned about the youth’s well-being, parents will be contacted. I am not to bring a cell phone or other electronics to camp.

I understand that campers are not to bring cell phones or other electronics to camp and agree to the above terms.

Camper Agreement

I agree to abide by all the camp policies and any restrictions my parents have stated.

Parent/Guardian Authorization

The above information is correct to the best of my knowledge. He/she has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp health care staff to order x-rays, routine tests, treatment and necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give my permission to the doctor selected by the camp health care staff to secure and administer treatment, including hospitalization for my above-named child. I further release Cedine from all liability beyond the accident insurance carried by the camp. Furthermore, I understand that pictures will be taken during my child’s time at camp, and I give my permission for the use of such pictures containing my child’s likeness (and/or my likeness) for the promotion of Cedine’s camp or conference ministry.

Refund and Transfer Policy

Refunds or Transfers to another camp must be made at least 14 days before the registered camp begins. The payments are transferable to another camp this year or next year depending on availability. You may transfer payments to an unregistered person of the same gender if you are unable to attend. No payments may be transferred to a person who is already registered. If you do not notify us at least two weeks prior to the camp, your deposit is not refundable or transferable.

I have read and understand the refund and transfer policy.

Upon clicking the Register button you'll be provided with a confirmation of your registration. Please print a copy before proceeding to the final step of submitting your registraion fees online!