In order for your child to attend RHEMA 2019 Summer Youth Camp – they must have attended Rhema Youth Church Services for at least the last 3 months.* I acknowledge that the camper I am signing up has attended Rhema Youth Church Services for at least the last 3 months. Full Legal Name of Student:* First Middle Last Age*Please enter a value between 0 and 100.Sex*MaleFemaleBirthdate* Tee Shirt Size (all adult sizes)*X-SmallSmallMediumLargeX-Large2X-Large3X-LargeParent or Legal Guardian's Full Name:* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Home Phone*Cell PhoneEmergency Contact (someone outside of home)* First Last Parent grants his/her permission for Child to attend the event noted above and acknowledges the RHEMA Bible Church youth workers will be the temporary custodians of the Child during the above said event Parent grants his/her permission for Child to be transported to and from the event, participate in swimming, movie, inflatable games, skating, basketball, bowling, and all other activities at this event. Parents releases and agrees to indemnify RHEMA Bible Church, and Kenneth Hagin Ministries, Inc., and their agents, officers, directors, employees, and volunteers (collectively referred to as "Rhema") from all liability for any harm to Child or Child's property, resulting directly or indirectly from Child's participation in skating, basketball, bowling, inflatable games, and other activities. Parent, individually and on behalf of the Child, personally assumes all risks and liabilities in connection with the child's participation in swimming, skating, basketball, bowling, transportation, inflatable games, and all other activities. Parent authorizes Rhema personnel to consent on Parent's behalf to any medical attention which they deem required by Child, and Parent assumes all liabilities for medical bills, claims for pain and suffering, civil damages, or any other liability resulting directly or indirectly from the medical attention. Parent understands and agrees that his/her consent is given in advance of any specific diagnosis or treatment. Further, this consent is given to encourage the physician, dentist, or surgeon, and those who have temporary custody of the minor, to exercise his/her best judgement as to such diagnosis or medical, dental, or surgical treatment.Family Medical Insurance Carrier*Policy #*List any disease, physical or mental limitation or medical conditions (asthma, seizures, diabetes, psychiatric disorders). If None please type None.*Presently taking any prescription or non-prescription medications?*YesNoIf yes, please list all and the dosageAre there any other conditions or limitations we should be aware of?*YesNoIf yes, please explain:Allergies (food, medication, insects, or other)*YesNoIf yes, please list all and dosage:Upon request, can your child have:*TylenolAdvilOtherNoneDoes your child swim?*YesNoIf yes, please select to rate the level of swimming ability you perceive for your child ("1" being lowest and "10" being highest)12345678910Sickness, Homesick, and Inappropriate Behavior:I acknowledge that if my child becomes ill, homesick, or displays inappropriate behavior and needs to return home during the camp, it will be my responsibility to come and pick up my child from RHEMA Ranch. Every counselor is needed to take care of the children. Counselors are not permitted to leave the retreat to provide transportation back to the RHEMA Campus. If your child does have to return home during the course of the camp due to being ill, homesick, or because of inappropriate behavior, your retreat/camp/event fee will NOT be pro-rated. Entering my name and checking the box below indicates that I have read the above and understand what is expected of me if my child needs to go home during camp.Name* First Last I consent to all of the information and requirements contained in this release form.* Yes, I consent EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.