New Hope Camp & Conference Center Home Page

Individual Registration Form

First Name: Last Name:

I am registering as part of a church group from: in
I am a youth participant.
I am a adult participant.

Address:

City: State: Zip Code:

Cell Phone: Home Phone:

Email Address:

Name(s) of Parent(s) or Legal Guardian (if under 18):

Will this be your first visit to NHCCC?

Yes
No

What other types of events (if any) have you preciously participated in at NHCCC?

Fees and Payment

Fee: $60 per person. This fee covers the program, four meals and two nights' lodging.

Payments: (please check the appropriate line or lines below and fill in the associated blank)

I will be paying:
My church will be paying

Refund Policy: If cancellation occurs ten or more weekdays prior to the event, all deposits and fees paid are fully refundable except for a $5 service charge. If "late" cancellation occurs, less than ten weekdays prior to the event, all deposits and fees paid are non-refundable, unless the cancellation occurs due to a verifiable medical or family emergency. Any amount of financial assistance recieved for a participant will be refunded to the provider of the financial assistance.

Health/Emergency Contact Information

Primary Emergency Contact: Day Phone: Evening Phone:

Alternate Emergency Contact: Day Phone: Evening Phone:

Please list any known allergies or health conditions requiring treatment, restriction, or other accommodation while at NHCCC.

Please list any special housing, dietary or other special needs.

Personal Insurance Information

Carrier or Plan Name: Group #:

Address:

City: State: Zip Code:

Name of Policy Holder (if other than participant):

Relationship to Participant:

Policy or Insurance ID#:

Emergency Medical Authorization

I hereby give permission for medical personnel selected by the Director of New Hope camp & Conference Center, Inc. (NHCCC) to order x-rays, routine tests, and treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. IN the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the NHCCC Director for any necessary medical treatment of my child or myself. I understand that all program participants are covered by NHCCC for medical claims due to accident on an excess basis (the insurance is excess over any other valid and collectible insurance available to the injured person).

Signature of parent or legal guardian or adult participant: Date:

Participant Covenant

Believing that I am a part of the faithful community of the whole people of God at the event, I promise to be responsible for my actions, abide by the community guidelines and be open in mind and heart to the teachings and leadings of the Holy Spirit. I promise to do my part to make the experience of all other participants and/or leaders one that is safe, enjoyable and free from unkindness and insensitivity.

I will:
† Refrain from the use of tobacco products, alcohol and illegal drugs during this event and while traveling to or from this event.
† Refrain from inappropriate sexual behavior during this event.
† Participate in all scheduled activities and honor all meeting times
† Abide by all quiet-times, or curfews scheduled or announced
† respect the personal belongings and residential spaces of others by not entering any residential rooms or buildings that are not my own
† Do no intentional or careless harm to the personal belongings of others or to the buildings, grounds, equipment or other resources of New Hope Camp
† Respect the role of responsible adult leaders from my church and the event leaders by maintaining and constant communication with my church group leader(s) so that my whereabouts and personal safety are not of concern.
† Constantly seek to be a faithful and responsible example for the group at this event.

I understand....in a community based on love, respect, trust and support, each participant is responsible for his or her own actions. I also understand that if I fail to live up to the expectations of this covenant, I may be sent home at the discretion of the event director and at the expense of the participant or his or her parents.

Signature of Participant: Signature of Parent(s) or Guardian: