2026 Youth Camp (Grades 6-12)

Child #1 Information

First and Last Name:

Church Campus

Shirt Size:

Gender:

Date of Birth:

Age:

Grade Next Fall (2026-2027):

Is this child in foster care or adoption?

Please list any chronic/recurring medical conditions:

Does your child have any restricted activities? If yes, please explain.

List any allergies:

List any physical disabilities or limitations:

Can your child be given: (Check all that apply)

Tylenol Benadryl Ibuprofen Over the counter, non-prescription medications for stomach discomfort, burns, cuts, etc.

Current medication(s) needed during camp:

Child #2 Information

If this does not apply, please scroll down to "Parent/Guardian Information."

First and Last Name:

Church Campus

Shirt Size:

Gender:

Date of Birth:

Age:

Grade Next Fall (2026-2027):

Is this child in foster care or adoption?

Please list any chronic/recurring medical conditions:

Does your child have any restricted activities? If yes, please explain.

List any allergies:

List any physical disabilities or limitations:

Can your child be given: (Check all that apply) Tylenol Benadryl Ibuprofen Over the counter, non-prescription medications for stomach discomfort, burns, cuts, etc.

Current medication(s) needed during camp:

Child #3 Information

If this does not apply, please scroll down to "Parent/Guardian Information."

First and Last Name:

Church Campus

Shirt Size:

Gender:

Date of Birth:

Age:

Grade Next Fall (2026-2027):

Is this child in foster care or adoption?

Please list any chronic/recurring medical conditions:

Does your child have any restricted activities? If yes, please explain.

List any allergies:

List any physical disabilities or limitations:

Can your child be given: (Check all that apply) Tylenol Benadryl Ibuprofen Over the counter, non-prescription medications for stomach discomfort, burns, cuts, etc.

Current medication(s) needed during camp:

Child #4 Information

If this does not apply, please scroll down to "Parent/Guardian Information."

First and Last Name:

Church Campus

Shirt Size:

Gender:

Date of Birth:

Age:

Grade Next Fall (2026-2027):

Is this child in foster care or adoption?

Please list any chronic/recurring medical conditions:

Does your child have any restricted activities? If yes, please explain.

List any allergies:

List any physical disabilities or limitations:

Can your child be given: (Check all that apply) Tylenol Benadryl Ibuprofen Over the counter, non-prescription medications for stomach discomfort, burns, cuts, etc.

Current medication(s) needed during camp:

Parent/Guardian Information

Parent/Guardian First and Last Name:

Relation to child(ren):

Parent/Guardian Mobile Phone:

Other Phone (if applicable)

Parent/Guardian Email:

This address will receive a confirmation email

Home Address:

Mailing Address (if different from home address):

Is there anyone your child(ren) should NOT be released to? If yes, please list name(s) below.

Emergency Contact

If parent/guardian cannot be contacted, please notify the following emergency contacts:

Emergency Contact #1 First and Last Name:

Emergency Contact #1 Phone Number:

Emergency Contact #2 First and Last Name:

Emergency Contact #2 Phone Number:

West Texas District Consent Form

By signing this form, I affirm that the information submitted is true and accurate to the best of my knowledge. I authorize the adult in charge to consent to medical treatment when either my assignee or I cannot be contacted. I understand that every effort will be made to contact me regarding medical attention given to my child. I understand that participants at Roaring Springs Camp and Retreat Center are liable for damage caused intentionally or maliciously. Damage caused by a participant will be billed directly to the participant responsible and their legal guardian. I understand that camp is a voluntary activity. All participants must be willing to cooperate with the overall spirit and schedule of the camp. I understand that every effort will be made to room church groups in the same cabins. However, due to the structure of the camp and the limited number of beds, this is not always possible. I grant my permission to the West Texas District Council of the Assemblies of God to use photographs (individual or group) and/or multimedia images and recording in the best interest of the West Texas District Council. I have reviewed the camp information sheet and gone over the camp and dress code policies with my child. I understand my Camp participant must sign a form to abide by camp and dress code policies. I have reviewed the camp dress code policies with my child, the camper participant.

I agree.

Parent/Guardian Signature (Please type first and last name)

Today's Date:

Plainview First Youth Consent Forms

1. I understand that all camp fees are non-refundable.

I agree.

2. The student(s) I am registering were enrolled in grades 6th-12th for the 25/26 school year.

I agree.

In consideration for being accepted by Plainview First Assembly for participation in the above listed activity, I, being 18 years of age or older, do for myself (and for and on behalf of my child-participant if said participant is not 18 years of age or older) do hereby release, forever discharge and agree to hold harmless Plainview First Assembly, its pastors, trustees, employees, agents, volunteers, or any other person connected with said church, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and/or the child-participant that occur while said child is participating in the above-described trip or activity. Furthermore, I [and on behalf of my child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

I agree

I am the parent or legal guardian of the child(ren) listed above and hereby grant my permission for him (her) to participate fully in the above listed activity. In the event that medical treatment is required and I cannot be reached, I hereby give my permission for a representative of Plainview First Assembly to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to hospital care, injections, anesthesia, or surgery, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation costs.

I agree

Payment

The total cost per camper is $255. A deposit of $50 will hold your student's spot but all payments and forms must be turned in by Sunday, May 24th.

Deposit Payment Amount

OFFICE NOTE

Optional Shirt Payments

Camp shirts are available at your discretion. They are $20 extra per shirt. Please indicate below if you would like to purchase one for your student. All payments for shirts must be paid by Sunday, May 24th.

Shirt Payment

Office Use Only

OFFICE NOTE

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2026 Youth Camp (Grades 6-12)

Description

Please Fix the Following