AYC CAMPER REGISTRATION

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HOME
ABOUT US
AYC 2021
LIFETRAKS
CONTACT US

HOME
ABOUT US
AYC 2021
LIFETRAKS
CONTACT US

Appalachian Youth Camp ~ Camper Registration

$175 per person

Youth 12-20 (must be 12 before Oct 1, 2019)

First Name*

Middle Name*

Last Name*

DOB (MM/DD/YYYY)*

Email Address*

Street Address*

City*

State*

Zip*

Mobile Phone*

Home Phone

Have You Attended AYC Before?*

YesNo

Church*

Church City & State*

Emergency Contact*

Relationship*

Emergency Cell Phone*

Do you have any food or medication allergies?*

YesNo

If yes, please explain

Do you have any medical, emotional, behavioral, or physical conditions?*

YesNo

If yes, please explain

Insurance Company Name

Policy Number

Sunday Night Arrival (Sunday night arrivals require pre-approval and will result in additional charges.)

Yes

Do you plan to stay in a dorm or cabin? (Cabin lodging will incur additional fees)*

DormCabin

Parent/Guardian Attestation: I attest that I am either an adult at least 18 years of age and I am registering for myself, or I am the parent or legal guardian of the minor child for whom I am registering.*

Yes

Consent for Medical Treatment: I give my consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care for either myself or minor child which is deemed advisable by and is rendered under the general or specific supervision of any licensed medical provider. It is understood that this authorization is given in advance of any specific diagnosis or medical care being required, but it is given to provide authority and power to Live God Ministries, Inc. personnel to give consent to any and all such diagnosis, treatment or medical care which the medical provider deems advisable. I understand that I will be responsible for all costs associated with such medical treatment. I also give permission for the camp nurse to dispense Tylenol (acetaminophen) or Ibuprofin if requested by my minor child.*

Yes

Consent for Photos and Videos: I give Live God Loud Ministries, Inc. permission to use photographs and videos of myself or my minor children in the use of the ministry's promotional materials including ministry websites and social media accounts. I understand that I can revoke this permission at any time by contacting Live God Loud Ministries, Inc. in writing.*

Yes

Digital Signature*

Today's Date (MM/DD/YYYY)*

Click the "Send Message" button to submit your registration.

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AYC Camper Registration

$175.00$175.00