Winter Camp 2015 Church Registration Instructions and Policies

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1 Winter Camp 2015 Church Registration Instructions and Policies Registration Instructions: 1) Choose your weekend(s). Prayerfully consider which available weekend is the best for your church. Bring your entire youth group to the Jr./Sr. High retreat (perfect for small youth groups) or bring your youth group separately to the Jr. or Sr. High retreats. 2) Register with Covenant Harbor as soon as you have made a decision about your Deep Freeze weekend. Download a registration form from our website. Fill out the necessary information and mail or fax it in to our registrar, Jane, with a deposit of $20 per student to reserve space in the weekend of your choice. Space will be given based on the numbers provided for church attendance. Registration will be handled on a first come first served basis. Confirmation letters will be sent to confirm dates and details as you register. 3) Promote the weekend at your Church. Hang posters, show videos and hand out flyers and registration forms. Covenant Harbor registration forms MUST be used; please contact us if you would like our form customized for you, and we will make a customized registration form for you. Do NOT modify or eliminate any part of the registration form. 4) Church Registration Form, Church Cost Calculation Form, Student Registration Forms, Adult Leader Registration forms, and full payment are due 3-4 weeks before your weekend. 5) Attend the Deep Freeze retreat and enjoy! Registration Policies: Payment: A $20 non-refundable deposit per student is due when you register in order to reserve your spaces. Full payment is due 3-4 weeks before your weekend. Retreats fill on a first come, first served basis. Housing: Churches will be housed based on availability and will likely share housing with other Churches. Leaders: Churches must bring at least one adult leader for each 6-8 students of each gender. All adult leaders must be 18 years old or older. Health Information/Health Release Form: Please note: Students attending winter camps with church groups are under the care and supervision of the youth pastors and adult leaders from the church registering the students to attend the retreat. Should students need medications or medical attention while at the retreat, it will be the church leaders responsibility to care for the student. Please see Health Information and Release Form for further information as your church will need to be sure you have permission and information to provide medical attention for your students. Cancellation: Churches are responsible to pay in full for each person they listed on the Church Registration Form (sent in 3-4 weeks prior to the event). Churches can replace a non-attending student with a new student of the same gender at any time without penalty, so long as new registration information is given to Covenant Harbor. Churches can replace a non-attending student with a new student of another gender if space allows. If space is not available for the new student of a different gender, the Church is still responsible to pay for the non-attending student. Please call or us with any further questions about Deep Freeze or the registration process. Covenant Harbor 1724 W Main Street Lake Geneva, WI Phone: (262) Fax: (262) Web:

2 Church Registration Form 2015 Select Your Retreat: Deep Freeze Jan (Jr/Sr High) Deep Freeze-Feb. 6-8 (Jr High) Winter Fest-Feb (3 rd -6 th grades) Deep Freeze-Jan (Jr High) Deep Freeze-Feb (Sr. High) Church Registration Instructions: Complete neatly in ink below and mail this form to Covenant Harbor 3-4 weeks prior to your weekend. This form must be accompanied by full payment, Church Cost Calculation Form, all Student Registration Forms and Adult Leader Registration Forms. Church Information: Church Name Church Phone Church/Youth Group Name (as you d like it on signs) Mailing Address City State Zip Code On-Site Retreat Contact Person Cell Phone used for further communication Leader Information: Churches must bring at least 1 adult leader of each gender for each 6-8 students of each gender. All adult leaders must be 18 years of age or older. Total Male Adult Leaders (number) Total Female Adult Leaders (number) Male Adult Leader 1 Female Adult Leader 1 for Male Adult Leader 1 for Female Adult Leader 1 Male Adult Leader 2 Female Adult Leader 2 Address -Male Adult Leader 2 for Female Adult Leader 2 Male Adult Leader 3 Female Adult Leader 3 Address -Male Adult Leader 3 for Female Adult Leader 3 Student Information: List first and last names of students, neatly, in ink. Male Students (total number listed below) Female Students (total number listed below)

3 Church Cost Calculation Form 2015 Church Registration Instructions Complete this form and the Church Registration Form and mail to Covenant Harbor 3-4 weeks prior to your weekend. These forms must be accompanied by full payment along with the Student Registration Forms & Adult Leader Registration Forms. Make sure to keep a copy of these completed forms for yourself. Deep Freeze / Winter Fest Program Rate Traditional Lodging (bunk beds, indoor washroom, shared room with other churches) Student Cost: $144 Adult Leader Cost: $99 Calculate Your Total Church Cost Student Calculation Student Rate $ 144 X Number of Students Adult Leaders Calculation Churches must bring at least 1 adult leader of each gender for each 6-8 students of each gender. Adult Leader Rate $ 99 X Number of Adult Leaders Subtract persons paying Covenant Harbor directly by check or credit card. Subtotal: Student and Adult Leader Costs: $ Student Rate $ 144 X Number of Students paying camp directly Number of Adult Adult Leader Rate $ 99 X Leaders paying camp directly Subtotal Deduction: Student and Adult Leader paying Covenant Harbor directly: $ - Additional Deduction: Deposit amount sent to Covenant Harbor: $ - *Total Balance Due: $ *Balance is due at Covenant Harbor 3-4 weeks before your weekend starts. Cancellation Policy Churches are responsible to pay in full for each person they listed on the Church Registration Form which is sent in 3-4 weeks prior to their selected weekend. Churches can replace a non-attending student with a new student of the same gender at any time without penalty, if a new student registration form is turned into Covenant Harbor. Churches can replace a non-attending student with a new student of another gender, if space allows (you must contact our registrar and inquire about available housing) and a new student registration form must also be turned into Covenant Harbor. If space is not available for the new student of a different gender, the Church is still responsible to pay for the non-attending student. Exceptions may be made for medical reasons, when a doctor s verification is presented prior to the start of the retreat. Completing Your Church Registration Mail this completed form, the completed Church Registration Form and your full payment to Covenant Harbor at the address listed above to arrive at Covenant Harbor at least 3-4 weeks prior to the weekend you have chosen. It is important that you keep a copy of these forms for your use.

4 2015 Deep Freeze Student Registration Turn in your registration form and payment to your church youth leader. Parent/Guardian Information - Used for all correspondence and emergency contact. Please print clearly, in ink. 1-Last Name 1-First Name 1-Middle Initial 1-Home Phone 1-Work Phone 1-Cell Phone 1- Address 2-Last Name 2-First Name 2-Middle Initial 2-Home Phone 2-Work Phone 2-Cell Phone 2- Address Mailing Address City State Zip Code Student Information - Only one student per form. Last Name First Middle Initial Date of Birth Gender (circle one): M F Grade ( school year) Name of School / / Select a Program - Price includes 2 nights lodging, four meals and most onsite activities. Adventure activity tickets are available onsite for a $5 fee. Weekend Dates: Fee: $ 144 Church Name (Required): Food Allergy / Dietary Restrictions - Attach additional information if necessary. List all food allergies or dietary restrictions or write None Important Note to Parents/Guardians: Students attending winter camps with church groups are under the care and supervision of the youth pastors and adults leaders from the church registering the students to attend the retreat. Should students need medications or medical attention while at the retreat, it will be the church leaders responsibility to care for the student. Parents/guardians should provide a copy of the student s health insurance card and information regarding medications and other medical needs to the adult leaders from the church. Cancellation Policy - When attending Deep Freeze with a church, cancellations should be communicated to your church leader. Generally, cancellations made more than 1 month before the event will receive a full refund minus the non-refundable deposit of $20 per person. Cancellations made less than 1 month before the event will receive no refund. Exceptions may be made: 1) for medical reasons, when a doctor s verification is presented prior to the start of camp; 2) when a non-attending student can be replaced with another student. Exceptions are not guaranteed. Consent and Release - I hereby give my consent to have the above-named Student fully participate in all camp activities, outings and field trips conducted on and off the campus of Covenant Harbor recognizing that there are risks known and unknown, foreseeable and unforeseeable involved in participating in these or similar activities. Covenant Harbor has taken reasonable and prudent steps to reduce known and foreseeable risks. I understand activities may be strenuous and/or outdoors and agree that participation in activities is voluntary. I understand and agree that neither Covenant Harbor nor its trustees, officers, directors, employees, agents or representatives may be held liable in any way for any injury, harm, damage or death which may occur to the above Student as a result of participation in these activities and hereby release, save and hold harmless the above mentioned of said injury due to participation in these activities. Further, I do consent to any and all medical treatment that may be deemed necessary for the Student should he/she require such assistance. I agree that my insurance plan is the primary plan to pay for the medical, dental or hospital care or treatment that is given to the Student. I agree to allow Covenant Harbor to transport Student as needed and to use a photocopy of this form as my authorization when necessary. Covenant Harbor may use the Student's photo, films, digital images, videotapes and sound recordings in future promotional materials. I have read and voluntarily agree to the statements herein. Polar Bear Dip: My student may participate in the polar bear dip (only available at Deep Freeze weekends) Yes No Signature of Parent/Guardian or Student Age 18+ X Printed Name Date Method of Payment Check enclosed payable to the Church you re attending with OR Credit Card Payment (Must be for full camp fee) Type: Visa Master Card Payment Enclosed: $ (includes $20 non-refundable deposit) Credit Card Number Expiration Date Security Code: Name on Card: Authorized Signature X Completing your Registration Please turn in your registration form and payment to your church youth leader. Do not mail this form to Covenant Harbor.

5 2015 Deep Freeze Adult Leader Registration All Adult Leaders must be 18 years old of age or older. Please turn in your registration form to your church youth leader. Adult Leader Information - Only 1 adult leader per form. Please print clearly, in ink. / / Last Name First Name Middle Initial Date of Birth Home Phone Work Phone Cell Phone Gender (circle one): M F Address Mailing Address City State Zip Code Emergency Contact Information Last Name First Name Middle Initial Home Phone Work Phone Cell Phone Select a Program - Price includes 2 nights lodging, four meals and all onsite activities. Weekend Dates: Church Name (Required): Food Allergy / Dietary Restrictions - Attach additional information if necessary. List all food allergies or dietary restrictions or write None Important Note to All Leaders: Students attending winter camps with your church are under the care and supervision of the youth pastors and adults leaders from your church. Should students need medications or medical attention while at the retreat, it will be your responsibility to care for the student. Parents/ guardians should provide a copy of the student s health insurance card and information regarding medications and other medical needs to the adult leaders from your church. Cancellation Policy When attending Deep Freeze with a church, cancellations should be communicated to your church leader. Generally, cancellations made more than 1 month before the event will receive a full refund minus the non-refundable deposit of $20 per person. Cancellations made less than 1 month before the event will receive no refund. Exceptions may be made: 1) for medical reasons, when a doctor s verification is presented prior to the start of camp; 2) when a non-attending adult leader can be replaced with another adult leader. Exceptions are not guaranteed. Weekend Retreat Release - It is Covenant Harbor's policy to ask the following question of all staff, leaders, and volunteers who have contact with children or youth at Covenant Harbor. Have you ever been charged or convicted of any crime involving the abuse or molestation of a minor? If yes, please explain on the reverse side. Consent and Release I hereby give my consent to have the above-named Adult Leader fully participate in all camp activities, outings and field trips conducted on and off the campus of Covenant Harbor recognizing that there are risks known and unknown, foreseeable and unforeseeable involved in participating in these or similar activities. Covenant Harbor has taken reasonable and prudent steps to reduce known and foreseeable risks. I understand activities may be strenuous and/or outdoors and agree that participation in activities is voluntary. I understand and agree that neither Covenant Harbor nor its trustees, officers, directors, employees, agents or representatives may be held liable in any way for any injury, harm, damage or death which may occur to the above Adult Leader as a result of participation in these activities and hereby release, save and hold harmless the above mentioned of said injury due to participation in these activities. Further, I do consent to any and all medical treatment that may be deemed necessary for the Adult Leader should he/she require such assistance. I agree that my insurance plan is the primary plan to pay for the medical, dental or hospital care or treatment that is given to the Adult Leader. I agree to allow Covenant Harbor to transport Adult Leader as needed and to use a photocopy of this form as my authorization when necessary. Covenant Harbor may use the Adult Leader's photo, films, digital images, videotapes and sound recordings in future promotional materials. I have read and voluntarily agree to the statements herein. Signature of Adult Leader X Printed Name Date Completing your Registration Please turn in your registration form and payment to your church youth leader. Do not mail this form to Covenant Harbor.

6 Health Information and Release Form for your church to keep and bring to the weekend Please note: Students that attend our winter camps are under the care and supervision of the youth pastor and adult leaders from the church registering the students to attend the retreat. Because of this, you must have a Health Release Form with you at the retreat for each student you bring to the retreat. This will help protect you and your church in case of an injury requiring emergency treatment. If your church does not have a permission slip or release form, you are welcome to use the following form. This is the information we suggest you collect. Please fill in the name of your church on line below and in the Consent and Release area before distributing. Health Information & Release Form for Name of church Student s Full Name: Date of Birth: Gender: Address: City: State: Zip Parent(s)/Guardian(s) Full Name(s): Home Phone: ( ) Address: City: State: Zip Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Emergency Contacts: If above listed parents/guardians are not available in an emergency, please notify: Contact Full Name (not parent/guardian): Relationship: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Medications: Please list all medications. Attach extra paper, if needed. Bring enough prescription medication (or over-the-counter medicine) to last the entire time at camp. This student takes no medications on a regular or as needed basis. I will skip this section and continue on. This student takes the following medications: Med 1: Dosage Specific times taken each day Reason for taking: Med 2: Dosage Specific times taken each day Reason for taking: Restrictions: The following restrictions apply to this student: Insurance Information: I have attached a clear photocopy of both sides of my insurance card to this form. (Required, if insured.) Additional Information: Is there any information about the student s behavior and physical, emotional, or mental health about which the youth pastor and adult leaders should be aware? Attach additional paper, if needed. Consent and Release: I understand that [fill in name of church] church s youth pastor or adult leaders are solely responsible for my student s health and wellbeing while they are attending the weekend retreat at Covenant Harbor. To the best of my knowledge my child is in good health and I have fully disclosed all medical, psychological and/or emotional problems or concerns to the leaders who are also attending this retreat. The student herein described has permission to engage in all camp activities except as noted and to participate fully in a physically rigorous program both on and off the camp grounds, to be transported, and to participate in outings, and field trips conducted off Covenant Harbor's grounds. This completed form may be photocopied for trips out of camp. I hereby give permission to above named church s youth pastor or adult leaders to provide routine health care, administer prescribed medication, order medication, secure treatment, seek emergency medical treatment including ordering x-rays or routine tests (and to order injection, anesthesia, and/or surgery) for the student named above. I agree to the release of any records necessary for insurance purposes or copied for transportation record. I give permission to above named church s youth pastor or adult leaders to arrange necessary related transportation for the above named student. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by above named church s youth pastor or adult leaders to secure and administer treatment, including hospitalization, for the student named above. I agree that my insurance plan is the primary plan to pay for the medical, dental or hospital care or treatment that is given to the student. Signature of Parent/Guardian or Student age 18+: Printed Name: I also understand and agree to abide by any restrictions placed on my participation in camp activities. Signature of Minor Student: Date: Date: Sign only if your parent/guardian has listed restrictions in the Restrictions area above.

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