Registration

Registration will be complete when payment is received. Payment made be made by PayPal/ Credit Card. Alternately registration form can be mailed to Heartland CEM, PO Box 10401, Midwest City, OK  73140.

Registration/ Information Form

This form requires the approval of camper and parent(s)/guardian(s)

Fields in bold are required:

(blank if camper goes by first name)

(Email and MySpace addresses allow us to contact campers with event information)

(On December 29, 2008)

  Male

  Female

(include year)

  


eSignatures    

This form uses Huggins' Email Form Script

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.