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