Select Camp(s) to Attend (*)
Please select at least one camp
Camper Information
First Name (*)
Required
Middle Name
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Last Name (*)
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Preferred Name
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Suffix (Jr., III, etc.)
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Camper Email (for announcements, etc.)
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MySpace (alternate announcements)
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Address (*)
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City (*)
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State (*)
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Zip Code (*)
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Phone
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Gender (*)
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Date of Birth (mm/dd/yyyy) (*)
Required (mm/dd/yyyy)
T-Shirt Size (*)
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Church (*)
Required
Has camper previously attended a Heartland camp? (*)
Required
Roommate Request
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Camper eSignature (*)
Required
Parent/Guardian Section
Off-campus transportation:
I understand that during camp the above named minor may be transported off campus via bus or van due to planned structured and supervised events.
Medical Release Info:
I hereby agree to hold harmless the Heartland Conference of the Pentecostal Holiness Church, the Church Education Ministries, and camp personnel in case of accident or injury sustained by my son/daughter at camp.
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.
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.
Notes (additional info you want to submit)
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Medical Condition(s)
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Medications Camper Is Taking
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Known Allergies (besides medications)
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Known Medical Allergies
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Parent/Guadian Name(s) (*)
Required
Email for registration confirmation (*)
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Re-enter email (*)
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Emergency Contact Number(s)
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Parent eSignature (*)
Required
