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Summer Camp Registration [Home Page]

To MAIL in, click here to print the forms, then mail the completed forms along with your check to John Knox Center.
( Requires Adobe Acrobat Reader )

Fill in entire page for the first child only. For each additional child fill in the first line and any information that is different.

PART 1 - Camper Information


*Camper's Name:

Nickname (if preferred) :

Birthdate: Age:

Gender:

Rising Grade in Fall:

School:

Camper Email:

T-Shirt Size:

Roommate Request:
(WE WILL HONOR 1 MUTUAL ROOMMATE REQUEST PER CHILD)

Comments:


My child swims:

Has your child attended camp at John Knox before?
Other JKC event attended:

Is this your child's first extended stay away from home?

Please tell us if there has been any life changing event in the past year for your family:

What would you like your child to gain from their camp experience?

Person(s) NOT authorized to pick up child:


If your child would like to attend multiple camp sessions this summer please select all that apply. The number of campers per camp is limited and will be filled on a first come first serve basis. Sorry, spaces may not be reserved by phone or without the non-refundable registration fee. Register early!! All fees include a $40.00 Registration Fee per camp session.

Realizing that families have different abilities and resources to pay for summer camp, this year, John Knox Center is introducing a voluntary three-tiered pricing program. You may choose the tier that is most suitable for your family. It is a "free-will" system; you pick the level that is comfortable and affordable for you. Our goal in introducing tiered pricing is simple. We want to continue to provide Christ centered programming in a safe, welcoming and fun environment, while offering opportunities for partnership for those who value this ministry and wish to help preserve John Knox Center for generations to come.

  • Tier I - This is the lowest rate and is the subsidized rate John Knox Center has historically offered. This price does not reflect what it costs for a camper to attend summer camp.
  • Tier II - This is a partially subsidized rate for families who wish to pay a little more and help support the John Knox Center ministry, but cannot afford the full price of camp.
  • Tier III - This rate most closely reflects what it costs for a camper to attend summer camp at John Knox Center, including facility upkeep and maintenance, staffing, utilities, and equipment.



Camp

Date

Tier I Cost

Tier II Cost

Tier III Cost


Covenant Partners (Age 16 -18) *Please contact Program Director, Penny Laitos to complete registration.

June 4th - June 16th

$525

$595

$750


Mini Camp

June 11th - June 14th

$210

$300

$360


Critter Day Camp

June 12th - June 16th

$150

$195

$250


Marathon Camp

June 18th - June 30th

$495

$795

$1200


Middle School Adventure Camp

July 5th - July 14th

$565

$710

$910


Native Ways Camp

July 9th - July 14th

$330

$475

$600


Native Ways Day Camp

July 10th - July 14th

$150

$195

$250


Night Owl Camp

July 16th - July 21st

$350

$495

$700


Sr High Adventure Camp

July 16th - July 26th

$595

$760

$1010

PART 2 - Family Information


Camper's Family or Guardian's Name:    Residential Phone:

Address:
City: State: Zip:

Family Status: Other or Custody:


Father's Name:

Father's Address if different from above:
City: State: Zip:

Father's Business Phone:

Father's Cell Phone:

Father's Email Address:


Mother's Name:

Mother's Address if different from above:
City: State: Zip:

Mother's Business Phone:

Mother's Cell Phone:

Mother's Email Address:

Email addresses will be used to convey information to parents. Please add us to your email database.


Home Church:

Address:
City: State: Zip:


*Emergency Contact (NOT LIVING IN THE HOME)

Name: Relationship:
Work Phone: Home Phone: Cell Phone:

Second Emergency Contact (NOT LIVING IN THE HOME)

Name: Relationship:
Work Phone: Home Phone: Cell Phone:


INSURANCE INFORMATION

Company Name: Policy Number:

Please check if you do not have insurance:

Doctor's Name: Phone Number:


Please tell us how you heard about us: Other:

PART 3 - Health History


Please explain any "yes" answers, noting number of the questions, in comments box below.

1. Had any recent injury, illness or infectious disease?Yes
No
14. Ever had back problems?Yes
No
2. Have a chronic or recurring illness/condition?Yes
No
15. Ever had problems with joints (e.g. knees)?Yes
No
3. Have frequent headaches?Yes
No
16. Have an orthodontic appliance being brought to camp?Yes
No
4. Ever have a head injury?Yes
No
17. Have any skin problems (e.g. rash, itching)?Yes
No
5. Ever been knocked unconscious?Yes
No
18. Have Diabetes?Yes
No
6. Wear glasses, contacts, or protective eye wear?Yes
No
19. Have Asthma?Yes
No
7. Ever had frequent ear infections?Yes
No
20. Had mononucleosis in the past 12 months?Yes
No
8. Ever passed out during or after exercise?Yes
No
21. Had problems with diarrhea/constipation?Yes
No
9. Ever been dizzy during or after exercise?Yes
No
22. Have problems with sleep walking?Yes
No
10. Ever had seizures?Yes
No
23. Have a history of bed-wetting?Yes
No
11. Ever had chest pains during or after exercise?Yes
No
24. Ever had an eating disorder?Yes
No
12. Ever had high blood pressure?Yes
No
25. Ever had emotional difficulties for which professional help was sought?Yes
No
13. Ever been diagnosed with a heart murmur?Yes
No
26. If female, have an abnormal menstrual history?Yes
No

LIST ANY ALLERGIES:

Comments:

Please give all dates of immunizations:

Vaccine Mo/Yr Mo/Yr Mo/Yr Mo/Yr
Chicken Pox
Hepatitis A
Hepatitis B
Influenza
MMR
Polio
Tetanus/Diphtheria

IMPORTANT:
ANNUAL HEALTH EXAMS ARE NOW REQUIRED FOR ALL CAMPERS. Documentation must be validated by a physician, physician's assistant or nurse practitioner and must have the camper's name, date of exam, and state they are able to participate in active programs or state their limitations. It must include the practice name, address and phone number. This can be faxed to 865-376-1719, emailed from the doctor's office to admin@johnknoxcenter.org, or mailed to the camp address.

The above information can be written on the doctor's form or practice letterhead, or a form for your convenience can be downloaded here.

Please notify the camp if the camper has been exposed to any communicable diseases within three weeks of their camp session.

PART 4 - Financial Information/Parent Authorization


All published camp fees include a $40.00 non-refundable processing fee. Registrations will not be accepted without it. All paperwork and fees must be received at least 2 weeks prior to the camp session or at the time of registering. Please note the change in the payment deadline policy. CAMPERS WITH AN UNPAID BALANCE 14 DAYS PRIOR TO THEIR SESSION WILL NO LONGER BE CONSIDERED REGISTERED FOR THIS SESSION. (excludes church scholarship) To receive a full refund (excluding the processing fee) please cancel at least 30 days before the first day of the camping session. Cancellations less than 30 days but more than 14 days will be refunded half the cost of camp. No refunds can be given under fourteen days notice.

Session(s) Total $

I would like to donate to the Camp Scholarship Fund $

I would like to donate to the Program Fund $

I would like to donate to the Debt Reduction $

I would like to donate to Capital Improvements $

Church Scholarship (amount to be paid by church) $

*TOTAL: $

*Method of Payment:

*Amount Paid: $


Parent Authorization

I hereby give my permission to the Presbytery of East Tennessee/John Knox Center for my minor, child or ward (collectively "minor") to participate in all activities and further agree to the terms herein contained. On behalf of my minor, to participate in John Knox Center (hereinafter collectively referred to as JKC/ PET) activities and to use its equipment and facilities, I agree to release, indemnify, hold harmless, and covenant not to sue JKC/PET, its employees, agents or volunteers for any and all liability, claims, demands, or causes of action which may be brought by myself, my minor, or on behalf of either of us, and which are in any way connected with such use or participation by my minor or myself, whether caused by the negligence of JKC/PET, its employees, agents, or volunteers, or otherwise. I acknowledge my minor's participation in individual and group initiatives, problem solving exercises, high ropes elements, waterskiing, whitewater canoeing and personal growth and development training activities entails known, perceived, and unanticipated risks that could result in serious physical or emotional injury, permanent disability, or death. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity and I expressly accept and assume on behalf of my minor all the risks existing in these activities. I acknowledge my minor's participation in programs may include transportation away form the John Knox Center property. I authorize JKC/PET personnel to transport my child as part of regular program activities.

I authorize JKC/PET personnel to call for medical care or to transport my minor to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed. I agree to pay all costs associated with such medical care and transportation. I hereby give permission to the John Knox Center staff to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for me/my child/ward, as may be necessary, including, but not limited to, x-rays, routine tests and treatment, and/or hospitalization. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I hereby agree to the disclosure to the John Knox Center staff of the protected health information of the person herein described. I also agree to comply JKC/PET rules and policies and to cooperate with JKC/PET personnel. I understand and agree that if myself or my minor fail to comply with the rules and policies, s/he may be asked to leave the event at the parent or legal guardian's expense, with no refund given for the paid cost of the event. I hereby represent that my minor is in good health, that I have identified all medical conditions applicable to participation, and that I have adequately informed JKC/PET personnel of any special instructions. I certify that I have adequate insurance to cover any injury or damage my minor may suffer while participating, or I agree to bear the costs of such injury or damage myself. I give my permission to allow JKC/PET to use my minor's likeness in photos and in any form of media for publicity and reporting purposes (print, digital, online, etc.). I agree that this release, waiver, and indemnity and other terms herein are intended to be as broad and inclusive as permitted by the law of the State of Tennessee and if any portion is invalid, the remainder shall continue in force.

I have read the above and acknowledge the information stated on this form is complete and correct. By typing my name below, I agree that this is an electronic signature. I understand that an electronic signature is legally binding in Tennessee.

SIGNATURE: DATE:


Please verify all information on this page then click FINISH & Pay Now.

NOTE: We now use PayPal for all Online Payment Transactions. Once you submit this page, you will be presented with a "Pay Now with PayPal" button. Please click "Pay Now with PayPal" to make payment via PayPal. You are NOT required to have a PayPal Account to complete your transaction. Applications will not be accepted if payment is not completed.

John Knox Center
591 West Rockwood Ferry Road
Ten Mile, TN 37880
Phone: (865) 376-2236
Fax: (865) 376-1719
Email: admin@johnknoxcenter.org
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