Pleasant Hill Youth Camp 2026 Registration Form

Student Information

Name

Birthday

Grade

School

This address will receive a confirmation email

Phone

Address

T-Shirt Size

S M L XL 2XL Other

If there are any allergies or medication we need to be aware of, please fill out below. Otherwise, respond to this question with "N/A."

Parent Information

Name

Address

Phone

This address will receive a confirmation email

Alternate Emergency Contact

Phone

Address

Consent Forms

I hereby consent to participation by my child in the Youth Camp 2026 event. I fully understand that this event will take place away from the church grounds and that my child will be under the supervision of the designated staff and/or volunteers on the stated dates. I understand that such an undertaking involves an element of risk. I assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless Pleasant Hill Church of Florence and its agents from any and all liability that may arise out of participation in this event.

I do consent. I do not consent.

I give consent for emergency medical treatment if necessary, as determined by the trip chaperones. I agree to hold harmless and release Pleasant Hill Church of Florence and its agents from any and all liability related to expenses arising from the giving of such medical care. As parent/legal guardian, I remain fully liable for any legal responsibility which may result from any personal actions taken by the named participant.

I do consent. I do not consent.

I hereby grant permission to Pleasant Hill Church of Florence to use my child's likeness on its promotional materials including, but not limited to video, websites, social media and printed materials without further consideration, and I acknowledge Pleasant Hill Church of Florence right to crop or treat the likeness at its discretion.

I do consent. I do not consent.

Payment

Pleasant Hill Church is asking for students to pay $160 for attendance to this event. You will notice an option that states "STS Full Payment." This is how much the camp itself is charging Pleasant Hill Church per student. If you feel led to pay this full amount in efforts to help recoup some of the costs to Pleasant Hill Church, you can do so by selecting this option. However, there is no penalty if you choose the $160. Thank you for your generousity.

If you choose the option "Pay in Person," you will be required to bring a deposit to the Pleasant Hill Church Office a week from turning in this registration form. Failure to do so will result in the student's spot remaining open until deposit is made.

Payment Options

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Pleasant Hill Youth Camp 2026 Registration Form

Description

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