Registration Type

Church Name

Location of Church (City/State)

Pastor Name (Must be UPCI Licensed)

Shirt Size? (This helps us anticipate sizes for future orders)

Name

Date of Birth

Age at the start of camp?

Phone Number

Address

Primary Guardian/ Emergency Contact - Name

Primary Relation

Primary Cell Number

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Secondary Guardian/Emergency Contact — Name

Secondary Relation

Secondary Cell Number

I have read and understand the Camp Policy and Dress/Conduct Code and have advised Camper of these rules and their obligation to abide by them.

I understand that I must download and sign the two waivers on the previous page.

Understand that I will be notified in case of a medical emergency involving the Camper. If I cannot be reached, I authorize the calling of a doctor and/or the providing of necessary medical services. I authorize the Camp Nurse and Staff to make emergency medical decisions on behalf of Camper as required by law. I understand the Texico District UPC will not be responsible for medical expenses incurred solely on the basis of this authorization. I agree to notify the Camp Office in the event of any health changes that would restrict Camper’s participation in any/all Camp activities. I understand that adult supervisors reserve the right to withhold Camper from any activity they feel is outside the physical capabilities of Camper. I also understand that my personal insurance (if applicable) is primary coverage, and the Camp Insurance is secondary.

Does your camper require prescription and/or over the counter medication?

NOTE: All medication must be turned in to the Nurses’ Station in original containers with doctor’s instructions. Use separate sheet if necessary.

I give permission for Camper to be given OTC medication provided by Camp Nurse for minor sickness (Tylenol, Motrin, Pepto Bismol, etc.) List any exclusions

Please list any exclusions:

Camper is physically fit and adequately prepared to participate in any/all activities of Camp unless otherwise noted in Camper’s medical information.

Yes
Camper and take part in all activites.
No
I will provide information during check in with the Nurse.

Camper has ANY allergies or food modifications?

Yes
Please provide information below.
No

If yes, please explain.

Health Insurance Information

Insurance Carrier and Phone Number

Insurance Group Number

Pastor Waiver

Running Total

$0.00

Coupon Code

Total

$0.00

BILLING INFO

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

Texico Youth Retreat 2026

October 30-31

REGISTRATION

Camper/Staffer Information

Contact Information

Additional Information

Health Insurance Information

Pastor Waiver

BILLING INFO