IMPACT CAMP 2025

CAMPER INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

Medical Forms: https://www.canva.com/design/DAGS26FC214/ZjbN1QcBmvZA8NZfWNxk-w/edit

NON-PRESCRIPTION MEDICATIONS ARE STOCKED AND KEPT WITH THE CAMP NURSE. THESE OVER-THE-COUNTER MEDICATIONS ARE USED ON AN AS NEEDED BASIS AND WITH THE NURSE'S BEST MEDICAL JUDGEMENT, TO MANAGE/TREAT ILLNESS AND/OR INJURY. 

THE FOLLOWING IS INVENTORY OF ALL OVER THE COUNTER MEDICATIONS AVAILABLE AT THE CAMP NURSE’S STATION:

ACETAMINOPHEN (TYLENOL), CALAMINE LOTION, IBUPROFEN (ADVIL, MOTRIN), BISMUTH SUBSALICYLATE (PEPTO-BISMOL), CLARITIN, ZYRTEC AND OR ALLEGRA, HYDROCORTISONE 1% CREAM, ROBITUSSIN, TOPICAL ANTIBIOTIC CREAM (NEOSPORIN), DIPHENHYDRAMINE (BENADRYL), ALOE VERA, GENERIC COUGH DROPS, CHLORASEPTIC (SORE THROAT SPRAY)

ACTIVITY AND PHOTO RELEASE

You or your child, (Collectively referred to as "Minor") wishes to participate in the following activities and gives permission to use photographs taken during the activities listed for any legal, advertisement, or social media sponsored by IMPACT YTH PCG (Pentecostal Church of God), CD (Central District).

IMPACT YTH PCG, CD and the undersigned Parent/Legal guardian of Minor agree that the activities may pose risks, including possible illness, injury, as well as similar and dissimilar risks. The undersigned is fully aware of the risks and other hazards inherent in the activities and is participating in the activity voluntarily and assumes the risks and all other risks of loss, damage, or injury that may be sustained while participating in the activity.

IMPACT YTH PCG, CD makes no representations or claims as to the condition or safety of the land, structures, transportation, or surroundings that may be involved in the activities, whether or not owned, leased, operated, or maintained by IMPACT YTH PCG, CD. It is understood that IMPACT YTH PCG, CD does NOT provide any insurance coverage for the Minor's persons or property, and Minor's Parent(s) or Guardian(s) acknowledge that they are responsible for the Minor's safety and the Minor's own healthcare needs, and for the protection of the Minor's property.

In exchange for allowing the following Minor to participate in these IMPACT YTH PCG, CD activities, the Minor, by and through the undersigned, the undersigned, and their respective heirs, personal representatives and estates agree(s) to release from liability and hold harmless IMPACT YTH, PCG CD and any agent, officer, or employee of the IMPACT YTH PCG, CD acting within the scope of their duties for any injury to the Minor's person or damage to the Minor's property. I authorize IMPACT YTH PCG, CD to take any action, including seeking medical care, necessary in its judgement if I am not present or reachable in the event of an emergency. The undersigned acknowledges that as a part of this release he or she will be 100% liable to pay for all medical expenses resulting or to result from any injury incurred during, or as a result of, participation in activities.

If any term of this agreement or the application to any person or circumstance shall, to any extent, be invalid or unenforceable, the remainder shall not be affected thereby, and each and every remaining term of this agreement shall be valid and enforced to the fullest extent permitted by law. In the event of any need to enforce this agreement, IMPACT YTH PCG, CD shall be entitled to its attorney fee and cost. This agreement will be governed by Missouri law.

I, the undersigned, state that I am the Parent or Legal Guardian of the Minor. I have fully read and understand the above terms and conditions and that they apply to said Minor and to myself, and that no oral representations, statements, or inducements apart from the foregoing written agreement have been made to the undersigned. This document is binding on myself, the said Minor, and any person suing on behalf of said Minor.

ADDITIONAL AUTHORIZATION & SIGNATURES

By signing, I am agreeing to understand all rules/regulations that are included within this camp registration form.  

By signing, I am agreeing to comply fully with them and to cooperate with camp administration.

*Any campers not willing to conform to all rules/regulations are subject to being sent home.  

By signing, the parent/legal guardian agrees to bear all responsibility in cost of picking up camper and no refund of any remaining time will be granted.

I, hereby, waive any and all claims against the PCG Central District, The Pentecostal Church of God, or any of its District Board, or its representatives, because of injury, or other damage that may be incurred to me or my personal property in connection with, or incident to, the Pentecostal Church of God. I understand that accidental medical insurance (Secondary) is provided in the camp cost, but that any personal medical insurance coverage information provided on this form is Primary. Rules of acceptance and participation in the program are the same for everyone without regard to race, color, national origin, age, sex or handicap. I also give Central District the right to use my picture, voice, and/or any testimony in any form of promotional or advertising materials. My enclosed signature signifies my approval of all limitations listed above.