LOCATION:

Louisiana Church of God of Prophecy Youth Retreat Church of God State Camp
6778 US Hwy 165
Friday, January 19, 2018 - Check in 5 p.m. Pollock, LA 71467
Saturday, January 20, 2018 - Check out 6 p.m.
Welcome Youth (ages 13-17), Youth Leaders, Camp Workers, and Pastors!!
$25 tuition
Name: _______________________________________________________
Age: __________ Date of Birth: _______________________ Gender: Male / Female
Street Address: _____________________________________________________
City: _____________________________________ State: ______________________ Zip: _______________
Parent/Guardian Name: _______________________________________ Phone (_____) __________________
Emergency Contacts: Name ___________________________________ Phone (_____) ___________________
Name ___________________________________ Phone (_____) __________________
Name of Local Church: _____________________________________________________
If there are any special instructions concerning who may or may not pick up your child from camp, please
specify: ___________________________________________________________________________________
__________________________________________________________________________________________

MEDICAL INFORMATION

Please list any health problems: ________________________________________________________________

List any medications currently being taken: ______________________________________________________
Date of last tetanus shot: _____________________________________________________________________
List any allergies: ___________________________________________________________________________
Health Insurance Company ___________________________________ Policy Number ___________________
Please attach a copy of your insurance card.
Family Physician: _______________________________________ Phone Number: ______________________

FOR NURSE SCREENING USE ONLY

Application _____ YES _____ NO
Head Lice _____ YES _____ NO

Applications are due by January 5, 2018.

Questions? Contact Alison Killingsworth at (318) 419-5898 or Alanne77@Bellsouth.net.

MAIL APPLICATION TO:

Alison Killingsworth
1093 Hwy 1241
Dry Prong, LA 71423
(318) 419-5898
CAMPER RULES AND REGULATIONS

1. An application must be completed for each camper and signed by a LEGAL guardian if under the age of 18.
2. Care should be given in choosing ones apparel. We are a Christian camp and campers clothing should reflect
Christian principles of modesty. Shorts and dresses must be at a decent length. Back and midriffs must
remain covered when standing or seated. Shirts must not fall below the cleavage line. Apparel that
symbolizes tobacco, drugs, alcohol, violence or profanity should not be worn.
3. The use of tobacco, drugs, alcohol or profanity is prohibited along with the possession of weapons, fireworks
or firearms. The LA camping ministry reserves the right to search camper, luggage or room. A violation may
result in dismissal from camp and notification of proper authorities if applicable. ALL MEDICATIONS
MUST BE KEPT BY THE NURSE!
4. Boys and girls should not be in each others cabins at any time.

DONT FORGET TO BRING:

Clothing
Towels / Washcloths
Pillow
Bedding

I agree to abide by all Camper Policy Rules & Regulations while I am a camper at LACOGOP camp.
Camper Signature _____________________________________________ Date ________________________

In the event of sickness or injury, I hereby grant permission to any physician / medical personnel selected
by the camp to give necessary medical treatment to the person registered on this form. I grant permission
for my childs picture to be used on our Church Camp Facebook Group page. I have read and
understand all information included on this application.
Parent / Guardian PRINT Name ______________________________ Relationship to Camper _____________
Parent / Guardian Signature ______________________________________ Date ________________________

FOR CAMP MANAGEMENT USE $25 tuition

TOTAL DUE: $ ________
Cash ______ Money Order _____ Church check__________