IMPACT Youth Registration

Parent/Guardian: Please fill out the following registration form.

Here are some notes about the form before proceeding:

  • You can register up to 5 youth (that you are responsible for) within this one form.
  • Digital Signatures are required for each youth on the Youth Conduct form section, so be sure they are available when you fill this out.
  • For each youth, there is a Medical Information section that is required to fill out.
  • There is a choice to indicate if your church will be making payment or if you are.
  • If you are making the payment, you will be redirected to the Tithely website after you submit the registration form. Once there, you will fill in your name and email. Then add the names of each youth in the attendee fields. Each youth cost $90.

If you need additional help or have questions, please contact April Johnson at moc.l1755851840iamg@1755851840cmcl.1755851840htuoy1755851840tcapm1755851840i1755851840

IMPACT Youth Retreat Registration 2025

Attendee (1st Youth)

Medical Information (1st Youth)

Must be filled out & signed by the custodial parent/guardian.

Please list all medications, including OTC and vitamins, the camper will be taking at camp.

Be specific and add additional pages as needed for instructions and additional items.

 

Please label all inhalers, EpiPens, medications with the camper’s name in permanent marker. All items will be held and administer by staff.  Please communicate medication needs with your chaperone upon registration.

EMERGENCY CONTACT INFORMATION: List at least one contact, must be someone OTHER than a parent.

MEDICAL INSURANCE INFORMATION

 

Attendee (2nd Youth)

Medical Information (2nd Youth)

Must be filled out & signed by the custodial parent/guardian.

Please list all medications, including OTC and vitamins, the camper will be taking at camp.

Be specific and add additional pages as needed for instructions and additional items.

Please label all inhalers, EpiPens, medications with the camper’s name in permanent marker. All items will be held and administer by staff.  Please communicate medication needs with your chaperone upon registration.

EMERGENCY CONTACT INFORMATION: List at least one contact, must be someone OTHER than a parent.

MEDICAL INSURANCE INFORMATION

 

Attendee (3rd Youth)

Medical Information (3rd Youth)

Must be filled out & signed by the custodial parent/guardian.

Please list all medications, including OTC and vitamins, the camper will be taking at camp.

Be specific and add additional pages as needed for instructions and additional items.

Please label all inhalers, EpiPens, medications with the camper’s name in permanent marker. All items will be held and administer by staff.  Please communicate medication needs with your chaperone upon registration.

EMERGENCY CONTACT INFORMATION: List at least one contact, must be someone OTHER than a parent.

MEDICAL INSURANCE INFORMATION

 

Attendee (4th Youth)

Medical Information (4th Youth)

Must be filled out & signed by the custodial parent/guardian.

Please list all medications, including OTC and vitamins, the camper will be taking at camp.

Be specific and add additional pages as needed for instructions and additional items.

Please label all inhalers, EpiPens, medications with the camper’s name in permanent marker. All items will be held and administer by staff.  Please communicate medication needs with your chaperone upon registration.

EMERGENCY CONTACT INFORMATION: List at least one contact, must be someone OTHER than a parent.

MEDICAL INSURANCE INFORMATION

 

Attendee (5th Youth)

Medical Information (5th Youth)

Must be filled out & signed by the custodial parent/guardian.

Please list all medications, including OTC and vitamins, the camper will be taking at camp.

Be specific and add additional pages as needed for instructions and additional items.

Please label all inhalers, EpiPens, medications with the camper’s name in permanent marker. All items will be held and administer by staff.  Please communicate medication needs with your chaperone upon registration.

EMERGENCY CONTACT INFORMATION: List at least one contact, must be someone OTHER than a parent.

MEDICAL INSURANCE INFORMATION

 

Youth Conduct Form

Must be filled out & signed by the custodial parent/guardian and each youth registered.

Youth Behavior:

  1. Youth and chaperones are expected to conduct themselves according to these guidelines for the duration of the trip (from the time your group begins the journey to the camp to the very end of the trip when your group is reunited with their families).
  2. Appropriate displays of affection may include side hugs, shoulder-to-shoulder hugs, pats on the head, shoulder or back, handshakes, high-fives, arms around shoulders and touching hands, faces, shoulders and arms.
  3. Inappropriate displays of affection: Even if in fun or as “horseplay” it is not acceptable for adults to engage with youth or youth to engage with one another in full frontal hugs, kisses on the mouth, touching bottoms, chests or private areas, showing affection in isolated areas of a building, touching knees or legs, wrestling, piggyback rides, tickling, massage or any form of affection unwanted by a youth.
  4. Appropriate Verbal Interaction -includes positive reinforcement, appropriate jokes, encouragement and praise.
  5. Inappropriate Verbal Interaction - Avoid any form of name calling, sexually oriented conversations with and between teens, involving youth in the personal problems of leaders, having secret elements of any relationship with youth, compliments related to physique or body development, cursing, off-color or sexual jokes, shaming, belittling, derogatory remarks or harsh language that may frighten, threaten or humiliate.
  6. Safe Media, Internet and Social Media Guidelines – The youth and their chaperones shall not watch restricted, adult or age-inappropriate movies videos. The sharing of inappropriate or unsupervised internet access and texting between adult leaders and youth under 16 without parental permission is not allowed. Cell phones may be collected by retreat leaders and safely stored for the duration of the trip. With permission from a chaperon and event leader a youth may be given their cell phone to contact their parents for relevant matters.
  7. If a youth observes the injury of a fellow youth or chaperone, inappropriate behavior or behavior that violates these guidelines by youth and other emergencies should be immediately reported to a chaperone. If the chaperone is involved in inappropriate behavior, it should be reported to the camp leaders.
  8. Students are expected to dress appropriately. Shorts must be of a modest length, no “short shorts” are allowed.  Shirts and tops should not display offensive language or pictures (language and pictures that do not reflect a Christian’s high calling in Christ). Shirts and tops should cover the midriff.
  9. Students must be in their assigned cabin at the conclusion of the last scheduled evening activity. Students must not leave their room or have anyone enter their room past the designated curfew time for that evening. Students should only leave in case of an emergency and must notify the chaperone. 

If a youth engages in activities in contravention of these guidelines and is asked to stop and refuses, the youth should be removed. The youth’s parents or guardians should be contacted, and the situation explained, and a request made for the parent/guardian to come and remove the youth immediately.

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Registrant Information

 

Church Information

 

Release & Waiver of Liability Agreement/Medical & Media Release Form

I give my permission for this youth to participate in all aspects of the retreat program except as noted above. I understand that it is my responsibility to bring any special concerns, medical or otherwise, about my youth to the attention of the chaperone before or at the time of time of registration. In the event I cannot be reached in an emergency, I hereby give permission to camp staff and/or chaperone to secure and administer treatment, including hospitalization, ordering injections, anesthesia, x-ray or surgery as deemed necessary for my youth named above. I accept responsibility for payment of such services. I will in no way hold Shoshone staff members, LCMC Board Members, retreat leaders or chaperones liable. I understand choosing to send this youth to this retreat may increase their risk of being exposed to communicable diseases such as flu or COVID. For the safety of other campers and leaders, I agree to not send this youth if I suspect they are ill. I give my permission for any picture or video taken of my youth to be used for promotional purposes unless I note otherwise.

BY SIGNING THIS DOCUMENT I acknowledge these policies and affirm that I am the legal parent and/ or guardian of the camper listed above.

Sign here. Use mouse for computer or finger for touch screen.

When you submit the form, you will be redirected to the Tithely website to make payment. Once there, you will fill in your name and email. Then add the names of each youth in the attendee fields. Each youth cost $90.