Life Demonstration | Youth Camp 2025

Student/Leader Name

First

Last

Gender

Male
Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Student/Leader Phone

Student/Leader Email

Health and Allergy Concerns:

Date of Birth (MM/DD/YYYY)

Age

School Grade This Fall

Do You Have a Bible?

Yes
No

T-Shirt Size

Parent/Guardian Name

First

Last

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact (Other than Parent/Guardian Listed Above)

First

Last

Emergency Contact Phone Number

Kiamichi Baptist Assembly Health Form

Here is the link to the health form. You can either print it out and hand it to Pastor Jake, or fill it out, scan it and upload it to this form below

Click this link

Upload Kiamichi Baptist Assembly Health Form Here

Click or drag a file to this area to upload.

Sunscreen Application Consent

You are being asked to authorize LIFE DEMONSTRATION CHURCH personnel (Pastor or Leaders) to provide your child with a commercial brand sunscreen lotion for his/her application in the case that your child forgets to bring his/her sunscreen in order for them to participate in planned outdoor activities.

If you permit your child to use sunscreen provided by the camp, you also agree to release, indemnify, and hold harmless LIFE DEMONSTRATION CHURCH and any of their staff and volunteers from lawsuits, claim, expense, demand, or actions against them for the application of sunscreen lotion for your child.

Choose one

I GIVE permission to the Pastor or Leaders to provide my child with a commercial brand sunscreen lotion
I DO NOT GIVE permission to the Pastor or Leaders to provide my child with a commercial brand sunscreen lotion

Photographic and Media Consent

Only check below if:

you DO NOT want the collection and use of your child’s personal images by photography or video recordin that may be used on the LIFE DEMONSTRATION CHURCH website, YouTube channel, newsletters, and publications as well as distributed to members or used for LIFE DEMONSTRATION CHURCH’s promotion in the future

No personal information, such as names, will be used in any publications unless express consent is given.

Click Below If You DO NOT CONSENT

I DO NOT GIVE CONSENT for LIFE DEMONSTRATION CHURCH to collect and use my child’s personal images by photography or video recording

RELEASE STATEMENT

I hereby consent to the participation of my child in all of LIFE DEMONSTRATION CHURCH’s Youth Camp supervised activities including Bible studies, indoor and outdoor recreational games, crafts, field trips, and lunch and snack times.

I, the Parent or Guardian named below, authorize LIFE DEMONSTRATION CHURCH’s personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above.

I, named below, undertake and agree to indemnify and hold blameless LIFE DEMONSTRATION CHURCH, its Personnel, its Leaders, and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of youth camp 2024, as well as of any medical treatment authorized by the supervising individuals representing LIFE DEMONSTRATION CHURCH. This consent and authorization is effective only when participating in or traveling to events of youth camp 2024.

I have read, understood and agree with the above

Name

First

Last