Koinonia Camp & Conference Center
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Weekend Retreat registration form 

    general registration & medical release form

    Please note our forms are for adult and minor campers.  Please fill out all required sessions as applicable for you.
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    please select all the camps you plan to attend.
    Please list the names of no more than four people or couples who are authorized to pick-up your child from camp. *Please send special written permission if camper is to leave camp during a session for practices, games, concerts, etc.
    please list one person you would like to room with.







    AUTHORIZATION FOR tREATMENT/ eMERGENCY cARE

        I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests and treatment; to release any records necessary for insurance  purposes; and to provide or arrange necessary related transportation for my child.  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp executive director to secure and administer treatment, including hospitalization for the person named above.  This complete form may be photo copied for trips out of camp.  The health history is correct and complete as far as I know.  The person herein described has permission to engage in all camp activities as noted.                                                                                                                        
         I agree to release and hold harmless Koinonia Camp, its employees and volunteers from any and all claims including, but not limited to physical or property damage suffered by my child as a result of attending a camp or travel during camp.  During travel, I understand that my child will be accompanied by a responsible adult and every precaution will be taken to safeguard the welfare of the campers. 


    Physical Activity Release

    ​      Camp Activities include, but are not limited to hiking, swimming, low and high Koinonia Adventure course activities, canoeing, horseback riding, archery and paintball adventure games.  There are risks of physical injury or harm from participating in high adventure activities.  I voluntarily elect to participate in the activities and assume the risks of injury of harm that could result from participation.  On my own behalf and that of my personal representatives and heirs, I hereby release Koinonia Camp its officers, employees, and agents from all liability for any injury or harm to me (or my minor) from participating in said activities; whether the injury or harm is caused by the negligence of Koinonia Camp or otherwise.  I have read and understood this release of liability.
          Participation in the physical aspects of any or all outdoor initiatives is absolutely voluntary.  I acknowledge the fact that not all of the stresses and hazards connected with the activities can be foreseen.  Some of the specific hazards I might encounter include slipping and falling on trails, bumps, bruises, cuts, scrapes, insect stings, poison ivy, sprains or other injuries.  Facilitators will take every reasonable precaution to minimize exposure to known risks.  I have the personal responsibility to follow all the safety rules and guidelines given to me.  I hereby personally assume all risks in connection with the activities and I waive all claims arising out of the safety rules and guidelines given to me.
    *Please note that by registering your child for this camp you are giving Koinonia Camp permission to take and use pictures and videos for promotional purposes.*
Submit
  • Home
  • Summer Camp Sessions
  • Retreats & One Day Events
  • Gallery
  • Newsletter
  • Equine Programs
    • Rough Riders!
  • Forms
    • One Day Event Form
    • Weekend Retreat Registration Form
    • Volunteer Staff Application
    • Equine Program Forms >
      • Equine Release Form
      • Rough Riders Participation Form
      • Rough Riders Volunteer Application
      • Ride-a-Thon Entry Form
  • Contact Us
  • Join In!
    • Give Your Time
    • Give Your Talents
    • Give Your Treasures
    • Donate
  • Camp Store
  • Ministry Partners
    • Benevolent Businesses
    • Partnering Ministries
  • About Us
  • Duck Race & BBQ Auction Fundraiser
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