Registration Options

Early Registration ($115.00)
Ends October 18
Regular Registration ($125.00)
Begins October 19

Camper Name

Church You Are Attending With

Date of Birth

Gender

Male
Female

Hoodie Size

Laser Tag Registration

Adults Only (Copy of Naz-Safe Certificate)

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Parent/Guardian Name

Mobile Phone Number

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Address

Emergency Contact

Emergency Contact Number

Medical Information

List name(s)/dosage(s) of any medications your student will be taking during EO Teen Camp

List any medical conditions or activity limitations

Date of last tetanus shot

Family Physician and Phone Number

Family Dentist and Phone Number

Insurance Provider/Phone Number

Insurance Policy Number

Medical Release

As parent/legal guardian, I do hereby give permission for my student to attend and participate in all activities for Fall Retreat 2026 sponsored by the East Ohio District N.Y.I. on
November 13-15, 2026.

We (I) authorize an adult in whose care the minor has been entrusted to consent to an X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or medical care facility.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred with such medical and/or dental services rendered to the student registered according to this authorization.

Should it be necessary for my student to return home due to medical reasons or otherwise, the undersigned will assume all transportation costs.

I, the undersigned, agree to the terms above.

Total

$0.00

Local Church Coupon Code (check with your leader)

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CAMPER REGISTRATION

PARENT / GUARDIAN INFORMATION

Medical Information