Camp 2019 Student Registration Form

Price: $205 student registered by June 14  

Price: $260 student registered by July 1 (Registration will close after July 1. Sorry… No walk-ins allowed)

Paintball - Additional Fee: $10 (optional)

 
Student Information
Name *
Name
Birthday *
Birthday
Adult Sizes
Home Address *
Home Address
I agree to abide by all guidelines and policies of the Prairie Lakes NYI for Camp and also agree to conduct myself in a manner that pleases God, my family, and my church. I also understand that disobedience to the rules could result in me being send home at my expense.
Parent/Guardian Information
Name *
Name
Phone *
Phone
Alt. Phone
Alt. Phone
Emergency Contact Information
(if parents can't be reached)
Name *
Name
Phone *
Phone
Medical Information
Date of Last Tetanus Shot *
Date of Last Tetanus Shot
Release of All Claims
I hereby approve the application, certify its correctness and expressly wave any and all claims against the Prairie Lakes Church of the Nazarene NYI, any of its District Boards, and its representatives because of any injury or other damage that may have incurred to my child or his/her property in connection with or incident to or travel to or from the Prairie Lakes NYI Camp and related events. Permission is hereby given for images of retreat experiences that include my child(ren)'s likeness to be used in promotions of camp activities. IN CASE OF MEDICAL EMERGENCY: I hereby understand that every effort will be made to contact parent or guardian listed. In the event I cannot be contacted, I hereby give permission to the physician selected by the staff to secure proper treatment of my child for and to any injections, hospitalization, anesthesia, or surgery for my child as named on this form.
Paintball (optional with additional $10 cost)
If selecting NO, you are finished registering and can click submit below.
In consideration of Prairie Lakes NYI furnishing services and/or equipment to enable me to participate in paintball games, I agree as follows:
I fully understand and acknowledge that; (a) risks and dangers exist in my use of Paintball equipment and my participation in Paintball activities; (b) my participation in such activities and/or use of such equipment may result in my injury or illness including but not limited to bodily injury, disease strains, fractures, partial and/or total paralysis, eye injury, blindness, heat stroke, heart attack, death or other ailments that could cause serious disability; (c) these risks and dangers may be caused by the negligence of the owners, employees, officers or agents of Prairie Lakes NYI; the negligence of the participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. These risks and dangers may arise from foreseeable or unforeseeable causes; and (d) by my participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, employees of Prairie Lakes NYI, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify Prairie Lakes District NYI and it’s owners, agents, officers and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of Paintball equipment or my participation in Paintball activities. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers or employees of Prairie Lakes NYI. This waiver is good through 12/31/2019.
(only if participating in paintball)
(only if student is participating in paintball)

 

Price: $205 student registered by June 14  

Price: $260 student registered by July 1 (Registration will close after July 1. Sorry… No walk-ins allowed)

Paintball - Additional Fee: $10 (optional)

HOW TO PAY: once you complete your form you can pay either through your local church and have them send a check or mail your payment to

Kalyn Haafke

116 N 12th St  Oakes, ND 58474

make check payable to PLD NYI. Please pay the full amount by July 1 (and don’t forget your paintball payment if you want to do that too!)