2024 Kansas Kids Camp Registration

Monday July 29 - Thursday August 1st @ Westminster Woods Camp in Fall River, KS

For students entering 4th-6th grades during the 2024 - 2025 school year.

Campers limited to the first 85 registrants.

Cost: $215
Checks payable to your home church.
Deadline to register & payment due date is June 26th.

(registrations paid after June 26th won't be guaranteed a t-shirt) Returned checks subject to a $30 service fee. Refund policy: Full refund if cancelled before June 26th, half refund if cancelled by by July 15th, no refund after July 15th.

Camper Information

Camper's Full Name

Gender

Date of Birth

Age

Grade going into Fall of 2024

Father's Name

Father's Phone Number

Father's Email Address

This address will receive a confirmation email

Mother's Name

Mother's Phone Number

Mother's Email Address

This address will receive a confirmation email

Camper lives with:

Camper's Permanent Address

Please select the church your child is attending camp with. If your church is not listed, please have your church leader contact Niki Copeland at ncopeland@gptopeka.org before registration can be completed.

Child is attending camp with the following church:

Emergency contacts other than parents: (e.g, grandparents, pastor, neighbor) Include name, phone number, and relationship

T Shirt Size

Is there anything you want your child's counselor to be aware of (e.g., changes in family life, learning disabilities, fears)?

Do you have any goals for your child at Kansas Kids Camp (e.g., social, spiritual, emotional, physical)?

Medical Information

Primary Doctor & Phone Number

Dentist & Phone Number

Do you have family health insurance?

Yes No

If yes, who is your Carrier and what is your Group ID #

Do you give permission to administer non-aspirin pain reliever, antihistamine, and/or lice treatment to this child?

Yes No

If other, please specify here:

Will your camper have daily medication to administer?

Yes No

Last Tetanus Immunization:

Are there any activities your child shouldn't participate in?

Permission to use photo/videos of your child for camp promotion/celebration.

Yes No

Medical Release

This health history is correct to the best of my knowledge, and the above named camper has permission to engage in all camp activities except as I have noted above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Kansas Kids Camp to hospitalize, secure proper treatment for, and to order injection(s) and or anesthesia and/or surgery for the above named camper. I understand that I am primarily responsible for any medical fees or prescriptions and charges arising from any illness or injury that the above named camper may incur. This completed form may be copied for transportation record. Type name and date below as agreement:

Liability Release

The undersigned, for himself or herself and personal representatives, assigns, heirs and next of kin, hereby releases, waives, discharges, and covenants not to sue The Wesleyan Church, the Kansas District, its agents, servants, and employees for injuries or illnesses incurred by the above named camper's participation in activities associated with Kansas Kids Camp. The undersigned is fully aware of the inherent hazards and hereby elects to participate voluntarily and assume all risks of loss, damage, or injury that may be sustained by the above named camper. Type name and date below as agreement:

Off-Camp Release

The above named camper has my permission to be transported and participate in outings and field trips conducted off the Westminster Woods Campground. It is understood that these outings are fully supervised by approved Kansas Kids Camp staff. Type name and date below as agreement:

2024 Kansas Kids Camp Registration

Description

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