Tweet You are invited to join us for worship on Sundays at either 8:45 or 11:00 a.m.! Christian Formation classes for all ages 24 months - adults at 10:00 a.m. Covenant Kids Camp Select one:*Trailblazer Girls (entering 3rd-4th grade) July 9-12 $245 after 6/1 $266Trailblazer Boys (entering 3 rd-4th grade) July 9-12 $200 after 6/1 $230Explorer Girls (entering 5th-6th grade) July 9-13 $305 after 6/1 $335Explorer Boys (entering 5th-6th grade) July 9-13 $245 after 6/1 $266*The difference in pricing for girls vs. boys is due to housing availability at Rocks Springs. (The girls will be housed in an air conditioned cabin while the boys’ will have attic fans). Please make checks payable to your local church.Name*Age*Grade (in fall)*Sex*MaleFemaleAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church Name*Birthdate* Date Format: MM slash DD slash YYYY Specify one desired roommateParents/Guardian NamePhone (Home/Cell)In case of emergency callInsurance Co.Policy #Does your child have any special needs the leaders and counselors should be aware of? Please explain:I authorize Covenant Kids Camp nurse to administer medications brought by the camper. Medication brought from home to be given while at camp must be in original container with the provided instruction sheet. The camp nurse will have the following over-the-counter medications available. Please indicate by circling yes or no whether or not your child can receive these medications if needed. TylenolYesNoIbuprofenYesNoBenedrylYesNoOtherYesNoIf a medical emergency should arise during the camper’s participation at Covenant Kids Camp, at a time when I am not personally present so as to be consulted regarding the camper’s care, I hereby authorize leadership of Covenant Kids Camp, on my behalf, to take whatever measures are necessary to insure that the camper is provided with any emergency medical treatment including hospitalization, which Covenant Kids Camp leadership deems advisable in order to protect the camper’s well-being and health. I specifically agree to hold Covenant Kids Camp leadership harmless as to any claim for damages for any accident or injury of any kind resulting from the participation of my minor ward in Covenant Kids Camp activities.Signature*Date Date Format: MM slash DD slash YYYY PLEASE COMPLETE REVERSE SIDE.Group: Covenant Kids Camp Date: 7/9/2018 – 7/13/2018Attendee's Name*Health List below any physical condition the doctor, EMT, nurse, Rock Springs staff or group staff should be aware of. (Any information will be kept confidential.) Check conditions present and list any pertinent information. Insect stings Diabetes Heart Condition Ear Infection Fainting Spells Headaches Asthma Allergies Allergies (Explain)*Allergic to any drugs (please list)Prescribed medicines presently takingDate of last tetanus immunization Date Format: MM slash DD slash YYYY Other conditionsParticipationRock Springs instructional staff is trained to provide the safest activities possible. I understand the campers will be closely supervised and agree that the supervisors, sponsors and Rock Springs 4-H Center are not responsible in case of injury or illness. I further understand that first aid will be available and that should a serious injury or illness occur, medical or hospital care will be provided. I realize the supervisors will notify me in case of serious injury or illness. However, should they be unable to contact me, I hereby grant my permission and consent for emergency medical or surgical care to be given, as determined necessary by a licensed physician. I give permission to Rock Springs 4-H Center, the Kansas 4-H Foundation and the Kansas 4-H Extension program to use pictures taken of my minor child while participating in activities at Rock Springs 4-H Center. I understand these photos may be used for the promotion of Rock Springs and cannot be sold or distributed to any other entity.SignatureDate Date Format: MM slash DD slash YYYY I specifically agree to hold Rock Springs 4-H Center harmless as to any claim for damages for any accident or injury of any kind resulting from the participation of my minor ward in Rock Springs activities including programs involving horses, and this “hold harmless guarantee” is specifically granted in consideration of the services by Rock Springs 4-H Center.Parent or Guardian’s SignatureDate Date Format: MM slash DD slash YYYY AddressIn case of an Emergency please notify:Day Phone #Evening Phone #Rock Springs instructional staff is trained to provide the safest activities possible. Because there is some inherent risk in Rock Springs outdoor activities, please check which type of activity you will allow for the above camper:May participate in all camp activitiesMay participate in all camp activities except those listed below.Please initial each that you do not wish the above camper to participate in: Canoeing Riflery Off-path Hiking Archery Swimming Horse Trail Rides Other Other This iframe contains the logic required to handle Ajax powered Gravity Forms.