4th-6th Chaperone Registration Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number(Required)Email(Required) Birthdate(Required) Month Day Year Gender(Required)MaleFemaleEmergency Contact(Required) First Last Emergency Phone(Required)Church(Required)CornerstoneDresden NazGrace LifeGrove City (The Naz)Heritage (Circleville)HilliardJacksonLife In ChristLoganLower LightsMariettaNewarkNew PhiladelphiaNorthwestObetzOne HopePataskalaPickeringtonThe RefineryReynoldsburgShepherdWest BroadWestervilleChildren's Ministry Pastor or Senior Pastor's Name, Phone Number, and Email Address(Required)HEALTH INFORMATION RELEASEHealth Insurance Company(Required)Card Holder's Name(Required)Policy Number(Required)If you are allergic to any medication, please list those allergies here:Please check all illnesses you suffer from, if any: Asthma Epilepsy Diabetes Other, please list below. Please list any other illnesses you suffer from that you think we should be aware of.Have you completed NazSafe Training?(Required) Yes, I have completed NazSafe Training. No. Please send me the information to complete NazSafe Training. Authorization, Release, Disciplinary, and Indemnification Agreement(Required) I agree that this is true and correct.I do hereby state that I am over 18 years of age and competent to electronically sign this form. 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.K. 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 being sent home. I understand that telephones are not available for campers use. In case of emergency, camp staff will notify the emergency contact 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 my being permitted to participate in the South Central Ohio Naz Kids Camps being held at Camp Cotubic in Bellefontaine, Ohio during the week of camp. I the undersigned ("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, my heirs, executors, and legal representatives. 4th-6th Early-Bird Registration Price: Early-Bird Registration is available through June 7th.4th-6th Registration Price: This field is hidden when viewing the formTimestampDiscount 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 is available through June 7th.4th-6th Discount Price: Total Credit Card Δ