OVCA Registration Form 2009
Name: ______________________________
Male ___ Female ____
Address: ____________________________
City:_________ State:___ Zip:__________
Home Phone: _______________Parents Work Phone: _________________
Emergency Contact Name and number:___________________________________
E-Mail Address (Optional): ____________________________________
Social Security Number: ______________________
Parent(s)/Guardian Name: _____________________
Birthdate: _________
Age as of today: ______________
Going into school grade: ____________________
Home Church: ________________
Church Phone number: ____________________
Minister Name: ________________
Minister Phone number: ____________________
Is your child likely to become homesick? Yes _____ No ___
Has your child been to OVCA before? Yes___ No ___
Has the child been immersed? Yes____ No ____
Please check the session you are registering for:
Check Week Attending | Camp Session | Camp Dates | Camper Age | Dean | Regular Camp Fees | Paid Before May 17 |
____ | Day Camp 1 | June 5 | Entering Kindergarten and First Grade | Sharon Sayre | $25.00 | $20.00 |
____ | Senior High | June 7-12 | Entering 9th, 10th, 11th, 12th grade | Brock Rohrer | $115.00 | $105.00 |
____ | Junior High 1 | June 14-19 | Entering 7th or 8th grade | Ron Ash | $115.00 | $105.00 |
____ | Junior 1 | June 21-26 | Entering 5th or 6th grade | Richy Newsom | $115.00 | $105.00 |
____ | Middler | Jun 28-July 3 | Entering 3rd and 4th grade | Ron Ash | $115.00 | $105.00 |
____ | Junior High 2 | July 5-10 | Entering 7th or 8th grade | Rodger Powell | $115.00 | $105.00 |
____ | Junior 2 | July 12-17 | Entering 5th and 6th grade | Doug Shamblin | $115.00 | $105.00 |
____ | First Chance | July 19-20 | Entering 2nd Grade only | Becky Pettit | $40.00 | $35.00 |
____ | Day Camp 2 | July 21 | Entering K or 1st grade | Sharon Sayre | $25.00 | $20.00 |
All fees include Snack Shack
Registration form to be sent to:
OVCA
P. O. Box 548
Pomeroy Oh 45769
A $10.00 non-refundable deposit is required with your registration. If the church pays the entire camp fee, no deposit need be sent. Deposits will be applied to the fees shown above. Send checks or money order only made payable to Ohio Valley Christian Assembly.
NOTE: The refund policy of OVCA is: Pro-rated refunds will be offered only to campers in cases of a death in the immediate family or for camper related medical conditions.
Amount your Church is paying(Circle): None Full Half Other
Name of Church paying fees:______________________________
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FOR CAMP USE ONLY
Registration Amount Paid $ _______
Date Received: __________
Camper paid at Camp $_______ Cash __ Check __
Paid by Church $ _______
Bill Church $ _______
Total Due at Camp $ ________Cash __ Check__
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Parent/Guardian must complete this page and sign below:
Child's name:______________________
(Print the child's name on this line above)
Check any illnesses your child HAS had: __Mumps __Chicken Pox __Asthma __Heart Disease __Measles __Ear Infection __Rheumatic Fever __Tonsillitis __Other:____________________
Check any Allergies to which your child is susceptible: __Poison Ivy __Penicillin __Hay Fever __Bee Sting
List other Allergies to which your child is susceptible: _______________________
Current Inoculation Date for Tetanus(if known): ______________________
The OVCA my give my child: __NONE __Aspirin __Tylenol __Mylanta __Pepto Bismol __Benedryl __Other as specified:____________________
NO CHILD IS TO BE BROUGHT TO THE CAMP ILL. ALL MEDICINES MUST BE LEFT WITH AND DISPENCESED BY THE CAMP NURSE. If your child has prescription medication, the CAMP will follow the directions on the bottle. DO NOT SEND MEDICINE OF ANY TYPE IN OTHER THAN THE ORIGINAL BOTTLE. If instructions have changed or need to be altered, please have your Pharmacist and/or doctor provide a new label before bringing the medication to Camp.
RISK OF INJURY ¨C WAIVER OF LIABILITY
A. I hereby give permission for my child to participate in recreational, swimming and learning activities and to be bound by all camp policies in force. Photographs will be taken as part of the week's activity and are for camp use only. ____
B. I desire that my child participate in the full range of camp activities and acknowledge that the natural conditions of the camp and the interaction with other children of various ages may subject my child to a risk of injury. ____
C. I therefore, release OVCA from any responsibility other than normal supervision and care. In case of accident, I will not hold Ohio Valley Christian Assembly, its staff, management, faculty, volunteers, officers or any supporting congregation liable. ____
D. In case of EMERGENCY, I hereby give permission to the physician selected by the camp management or Camp Dean to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child as named on this form. Doctor calls, treatment or hospitalization are to be charged to our family insurance or to me (parent/guardian) personally. I understand, however, that every effort will be made to contact me(parent/guardian) in case of such emergency, and if possible, before such medical treatment is administered. All medical care required for a camper shall be covered by the Camper¡¯s Health coverage below. ____
E. I have read and completed this Registration Form and the information I provided is correct. By signing below, I agree to the provisions contained in these documents. ____
Health Insurance Company: ___________________________________
Address: ________________________
Policy Holder: _____________________
Policy Group Number: ______________________
Signature(s) (Camper may sign if 18 years of age at date of signing)
Father-Male Guardian/Custodial Parent:_____________________________
Camper Date: ____________
Mother-Female Guardian/Custodial Parent:__________________________
Camper Date: ____________
Forms available by calling 740-992-5353 or requesting by email: ohiovalleychristian@yahoo.com

