Heidelberg West Youth Camp Heidelberg West Youth Camp Registration 2026 Heidelberg West Youth Camp Registration 2026 Name of Camper * Name of Camper First Name First Name Last Name Last Name Camper Age * Ages 10-18 or grades 5-12 Grade Level Just Completed * Sex * Male Female Can your child swim at least 25 yards (the length of a standard pool) without assistance and stay afloat for at least 5 minutes? * Yes No Please provide a headshot picture of your child * Drop a file here or click to upload Choose File Maximum file size: 20.97MB Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Cell Phone * Landline Phone Email * Church Personnel Request If you wish to be placed with a certain counselor or camper (parent, sibling, cousin, etc.), please fill in their name(s). Photo Release * Yes No Photos and videos taken during activities at camp may be submitted to the Reformed Herald or other church publications or used for future camp materials. Do you approve of the use of your child’s likeness for such purposes? Medical Restrictions * Please list any allergies or other medical restrictions. Medical Restriction File Upload Drop a file here or click to upload Choose File Maximum file size: 20.97MB If necessary, please upload any further instructions, doctor's notes, etc. Emergency Contact Name * Emergency Contact Name First Name First Name Last Name Last Name Emergency Contact Phone * Medical Release I/We, the undersigned parent(s) / guardian(s) of: Name Name First Name First Name Last Name Last Name a minor, do hereby authorize the staff of Heidelberg West Youth Camp as agents for the undersigned, to consent to any x-ray examination, medical or surgical diagnosis or treatment, and hospital care, which is deemed advisable by, and is to be rendered under, the general or special supervision of any duly authorized physician or surgeon. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on that part of our aforesaid agents to give specific consent to any and all diagnoses, treatment or hospital care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable. This authorization is given pursuant to provisions of Section 25.8 of the Civil Code of California, and affects the time period from Monday, July 14 through Friday, July 18, 2025. Consent for Medical Treatment Please select one or more of the following options for first aid treatment you authorize us to administer for your camper if the camp nurse determines it is needed: Checkboxes * Minor First Aid (Bandages and/or topical treatments for cuts / scrapes / sunburns) Basic over the counter medications Call me before administering Notes / Specific Details Signature Signature of Parent/Guardian * signature keyboard Clear Signature of Parent/Guardian (Optional) signature keyboard Clear Date of Signatures * Submit If you are human, leave this field blank.
