2024 Online Camp Form Written on March 30, 2023. Heartland Camp Registration Form 2024 Camp Selection Camp(*) High School Camp Regular — $175.00Middle School Camp Regular — $175.00Elementary Camp Regular — $175.00 Invalid Input Camper Information First Name(*) Required Middle Name Invalid Input Last Name(*) Required Preferred Name Invalid Input Suffix (Jr., III, etc.) Invalid Input Camper Email (optional — for announcements, etc.) Invalid format Address(*) Required City(*) Required State(*) OKAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Required Zip Code(*) Required Phone Invalid Input Gender(*) Male Female Required Date of Birth (mm/dd/yyyy)(*) Required (mm/dd/yyyy) T-Shirt Size(*) Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL Adult 2XL Invalid Input Church(*) Required Has camper previously attended a Heartland camp?(*) Yes No Required Roommate Request Invalid Input Notes (additional info you want to submit) Invalid Input Camper E-Signature(*) Camper agrees to abide by the Heartland Conference camp rules. This box will serve as an e-signature Required Medical Information Medical Condition(s) or special needs or accommodations the camp needs to be aware of. Invalid Input Medications Camper Is Taking Invalid Input Known Allergies (besides medications) Invalid Input Known Medical Allergies Invalid Input Authorized Pick Up Invalid Input Person authorized to pick up this child if other than parent named on form. You must call to verify if this changes. Parent/Guardian Section Parent/Guardian Name(s)(*) Required Email for registration confirmation(*) Invalid format Re-enter email(*) Invalid format Photo and Video Release(*) I understand that photographs and videos including my child engaged in the activities of the Heartland Camping program may be used for future promotional purposes of the Heartland Conference. Invalid Input Emergency Contact Number(s) Invalid Input Indeminification(*) I hereby agree to hold harmless the Heartland Conference of the Pentecostal Holiness Church, the Church Education Ministries/Discipleship Ministries, and camp personnel in case of accident or injury sustained by my son/daughter at camp. Invalid Input Medical Authorization(*) I do hereby authorize the Heartland Conference Church Education Ministries Director or his appointee to consent to any x-ray exam, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered to the above named minor under general or special supervision and upon the advice of a physician, surgeon or dentist licensed under law of the state of Oklahoma. Invalid Input Emergency Consent to Treatment(*) In giving this consent I recognize and understand that in situations where the above named minor requires immediate medical or hospital care it may not be possible to contact me, and that in such situations I authorize a physician, surgeon or dentist to exercise his/her professional judgment and assess the risk incident to and choose the necessary treatment from any available alternatives and to render such care and perform such treatment as his/her professional judgment determines to be necessary for the health or safety of the above named minor. Invalid Input OTC Medication Consent Medication Consent: I do hereby authorize the Heartland Conference Discipleship Ministries Director or her appointee to administer over the counter medications including but not limited to acetaminophen, ibuprofen, Benadryl. Invalid Input Parent E-Signature(*) As parent(s)/Guardian(s) of the above name minor, I/we do hereby give permission for camper to attend the Heartland Camp selected above. All information provided (including medical information) is true to the best of my knowledge. In the unlikely event that camper does not abide by the rules of the Heartland Camp, I/we will arrange for his/her early transportation home. Marking this box will serve as an e-signature. Required Pay by PayPal or Credit Card Created on March 30, 2023. Hits: 2022 Print
