4th-6th Camper Registration Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Age(Required)Birthdate(Required) Month Day Year Grade Completed(Required) 4th 5th 6th Gender(Required) Male Female Parent/Guardian Name(Required) First Last Parent/Guardian Phone Number(Required)Parent/Guardian 2 Name(Required) First Last Parent/Guardian 2 Phone Number(Required)Parent/Guardian Email Address(Required) ChurchCornerstoneDresden NazGrace LifeGrove City (The Naz)Heritage (Circleville)HilliardJacksonLife In ChristLoganLower LightsMariettaNewarkNew PhiladelphiaNorthwestObetzOne HopePataskalaPickeringtonThe RefineryReynoldsburgShepherdWest BroadWestervilleRelease Information(Required) This Camper should be released from Camp COTUBIC to their Children's Ministry Leader. This Camper should be released from Camp COTUBIC to the person listed below. Alternate Authorized Pickup Person (if applicable)First and Last NameHealth Information ReleaseHealth Insurance Company(Required)Card Holder's Name(Required)Policy NumberIf this camper allergic to any medication, please list them here, along with the reaction.(Required)Please check all illnesses this camper suffers from. Asthma Epilepsy Diabetes Other- Please List Below Any other illnesses or diseases this camper suffers from.If this camper is sensitive to insect bites, please list the insect(s) and their reaction(s) below.Is this camper allergic to poison ivy or poison oak?(Required) Yes No Medications Please check here if your child will need to take any medication(s) while at camp. All prescription AND non‐prescription medications must be turned in to the camp nurse at check‐in with printed directions for each child. All meds must be in original containers. Authorization, Release, Disciplinary, and Indemnification Agreement(Required) I agree that this is true and correct.I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered camper at Camp COTUBIC for South Central Ohio Kids Camp, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said Camp to consent to any X‐ray, examination, anesthetic, medical or surgical treatment, and/or hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state of Ohio, when such medical or surgical treatment is, in their opinion, necessary. I am aware that the administration of non‐prescription medicines (Tylenol, anti-acid, etc.) may be necessary. I willfully consent for my child to receive these if deemed necessary. No fireworks are allowed on the campground. No smoking, drinking of alcoholic beverages, or profanity is allowed on campground. We reserve the right to inspect the contents of all personal belongings at any time. The confiscation and/or disposal of improper contents is to the discretion of the S. C. O. Kids Camp Staff. In case of dismissal due to voluntary withdrawal or disciplinary action(s), there will be no refund of camp fees. I fully understand that failure to abide by camp policy may lead to my child being sent home. I understand that telephones are not available for campers use. In case of emergency, camp staff will notify the parent or legal guardian listed above. All camp safety measures will be met. The camp or camp staff will not be held liable for accidents. I understand that any pictures taken of campers while attending camp will become the property of Central Ohio District Kids Camp, and may be used for purposes of promoting Central Ohio District Kids Camp or shown on the internet. In consideration of the child listed above being permitted to participate in the South Central Ohio Naz Kids and/or Family Camps being held at Camp Cotubic in Bellefontaine, Ohio for the week of camp. I the undersigned being the parent or guardian ("Realeasor") hereby release, waive, discharge, covenant not to sue, agree to indemnify and hold harmless, the Church of the Nazarene, South Central Ohio District, Camp Cotubic and their officers, directors, agents, affiliates, employees and assigns ("Releasees") from any and all negligence of Releasees or otherwise, arising out of or relating to his/her presence or participation in the aforementioned South Central Ohio Naz Kids Camps and any activities related there to. This release shall be binding on myself, the above named camper, my heirs, executors, and legal representatives. This field is hidden when viewing the formTimestamp4th-6th Early Bird Registration Price: Early bird registration pricing is available through June 7th.4th-6th Registration Price: Discount CodeIf you have arranged group payment with the district, they will supply you with a discount code to complete the registration.4th-6th Early Bird Discount Price: Early bird registration pricing is available through June 7th.4th-6th Registration Price: Total Credit Card PhoneThis field is for validation purposes and should be left unchanged. Δ