Registration fee: Jr. High Camp $20 High School Camp $30

2012 Northeast Region Summer Youth Camp

Camper Info:

Check one:

_____High School Camp ________Jr. High Camp

Name ______________________________ Sex_______________

Address___________________________________ Zip__________

City__________________________________ state______________

Age____________ Grade________________ Phone (______)___________________

Local church Youth Coordinator Signature___________________________________

Pastor, Lay Missioner, or Lay Speaker Signature______________________________

Contact Info:

Emergency Contact Name __________________________________________

Relationship___________________________Phone(______)________________

Any Other Instructions_______________________________________________

Medical History___________________________________________________

Has or is subject to:(check if yes)

_____Asthma ______Fainting Spells _______Convulsions

_____Diabetes ______Allergies _______Heart Problems

_________________Reaction to medication if yes list____________________

Please list any allergies__________________________________

Has difficulty with (Check if yes)

______Eyes/ears/nose/throat _________digestion ________Menstruation

___________Lungs

Any Condition require regular medication? ____________________________________

Name of medication_________________________Dosage____________________

Any restrictions of activity for medical reasons?_______________________________

___________________________________________________________________

Insurance Company ______________________________________________

Policy________________________________________________________

Insurance Company Address_____________________________________________

Insurer's Name________________________SS#__________________________

Youth SS#_________________________DOB__________________________

Doctor’s Name___________________Phone____________________________

I hereby certify that the above information is correct and complete to the best of my

knowledge, and the person herein described has permission to engage in all prescribed

activities, except as noted above. The adult supervisors of____________________may authorize any and all medical treatment without liability.

_________________________________________ ___________________

Parent/Guardian Signature Date

I,_________________________________agree to abide by the rules of conduct as

determined by the Northeast Region Youth Ministries and the staff of the Northeast

Region Youth Camp.

I, the parent(s)/guardian of, _____________________do hereby consent that she/he will

follow all the rules and regulations as determined by the camp. I will not hold the

Oklahoma Indian Missionary Conference, local churches, or any individuals responsible

for any injuries or accidents that occur on the campgrounds, travel to and from the

campgrounds, or during any activities outside of the campgrounds.

Signature of the Participant____________________________________________

Signature of Parent/Guardian__________________________________________

Oklahoma Indian Missionary Conference

Guidelines for Conference Related Events

I Covenant to.....

1. Put God first in my actions, thoughts, and decisions.2. Set aside time each day to reflect and pray.3. refrain from using chemicals of any type including tobacco. i will not have

fireworks, firearms, knives, or any destructive weapons.4. Be where I am scheduled to be at appropriate times. 5. Participate, with enthusiasm, in all activities planned, as I know I am an example

for others and am representing God, my Family, My church and my conference.6. Refrain from using inappropriate language while on this event.7. Have a great week; be an encourager and take great ideas back home to share.8. Always use a “buddy system.” travel in groups of 3, at least.9. Do not leave designated areas without proper adult permission.10. I agree not to bring any electronic devices, such as radios, Cd's, games, Ipods,

cell phones, etc.11.No alcoholic beverages, drugs, firearms, fireworks, guns, knives, or tobacco.12.All medication should be turned into the designated medical person.13.Any participant who does not adhere to the covenant and/or guidelines will be

sent home at parent’s expense.14.Participants who drive to camp must relinquish keys to the dean until the

completion of the event.15. I understand that there will be no late or walk-in registration once the deadline

has been set.16.Participant and parent/guardian must sign registration.17.OIMC is not responsible for any thefts.

______________________________________________ _______________

Participant Signature Date

______________________________________________ _______________

Parent/Guardian Signature Date