Camp Kairos

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First name(required)

Last name(required)

Male or Female(required)

Age(required)

Date of Birth (MM/DD/YYYY)(required)

Home Addressrequired)

City(required)

State(required)

Zip Code(required)

Primary Contact Number(required)

Cell Home

Phone number(required)

Email(required)

Emergency Contact First Name(required)

Last Name(required)

Emergency Contact Phone number(required)

Camp Attending(required)

Teen Winter Retreat 2026 (Ages 13-19, $120) PeeWee Camp 2026(Ages 5-7, $120) Junior Camp 2026(Ages 8-12, $240) Young Adult Camp 2026(Ages 19-30ish, $120) Teen Camp 2026(Ages 13-18, $240)

Camper Shirt Size(required)

Desired Size if not an option above

Does the Camp have any Dietary Restrictions?(required)

Yes No

Please List all Dietary Restrictions (Please enter NA if you answered No)(required)

Does the Camper have any Allergies? (BeeStings, Penicillin, Peanuts, Fish, Gluten Free, Non-Dairy, etc.)(required)

Yes No

Please List all Allergens (Please enter NA if you answered No)(required)

Does our Staff need to be aware of any Medical Conditions? (ADHD, Bi-Polar, Depression, I.E.P or 504 Plan, etc.) (required)

Yes No

Please List any Medications or Accommodations our Nurse and Leadership Staff Need to be Aware of. All medications are to be administered by the camp nurse for campers 18 years or younger. The camp nurse will collect all medications at the time of registration (Please enter NA if you answered No)(required)

Are There Any Activities your Camper should not participate in?(required)

Yes No

If you answered Yes, please specify the activities or any accommodations we can do to include them in activities. (Please enter NA if you answered No)(required)

Does Your Family Have Health Insurance?(required)

Yes No

Medical Insurance Provider (Please enter NA if you answered No)(required)

Medical Insurance Provider Phone Number (Please enter NA if you answered No)(required)

Medical Insurance Group Number (Please enter NA if you answered No)(required)

Medica Insurance ID Number (Please enter NA if you answered No)(required)

Primary Care Provider Name (Please enter NA if you answered No)(required)

Primary Care Provider Phone Number (Please enter NA if you answered No)(required)

Medical Consent – I understand that if any accident or sickness should occur or is determined was transmitted during camp, which requires treatment emergency or otherwise, the campers private insurance will be considered the primary insurance. I understand that The Church of God of Prophecy Youth Camp, Camp Kairos, Camp Coordinators, Camp Directors, Camp Staff, Event Facility, and Facility Staff will not be held liable for any accident, sickness or expense relating to the any accident. In case of emergency, I understand that every effort will be made to contact the child’s Parent/Guardian, or Emergency Contact. If the Parent/Guardian, or Emergency Contact cannot be reached, permission is hereby given to the camp staff and/or physician to secure proper treatment for and/or hospitalization and to administer injection, anesthesia, surgery and/or other emergency treatment deemed necessary for the minor child above.

Choose one option (required)

I Agree (By checking this box, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, and agree to the terms of the attached Release and Waiver of Liability. I understand that checking this box represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) I Disagree

Release For Participation – I (we), the parents(s) or guardian(s) of the above listed minor grant permission for our minor to participate in all activities at Camp Kairos, this can include but not be limited to paintball and swimming. I (we) also release and agree to hold harmless Camp Kairos and The Church Of God Of Prophecy and all its participants from any liability and assume all risk of injury, damage or expenses as a result of participation in activities at Camp Kairos. In case of emergency, I give permission for the leadership of Camp Kairos to provide and/or arrange emergency care for my minor, and to arrange for transport to an emergency center for treatment if deemed necessary. I grant consent to medical treatment deemed immediately necessary or advisable by a physician if I am unable to act on my minor’s behalf. I further understand the Camp Kairos and The Church Of God Of Prophecy is not responsible for payment for such medical treatment. I also give permission for Camp Kairos to use any photo or video of my child for publications, social media posts or promotion and advertising. I release my right to any kind of remuneration, credits, or discounts for said photos or videos.

Choose one option (required)

I Agree (By checking this box, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, and agree to the terms of the attached Release and Waiver of Liability. I understand that checking this box represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) I Disagree

Camp Rules – I understand and agree that the camper will abide by all the rules, policies and discipline of the camp set forth by the director and staff. The rules & Policies can be found under the Parents tab on the main Camp Kairos web page. Any camper that engages is illegal activities, endangers others, or refuses to conform to the camp rules is subject to being sent home immediately. The parents or guardians will be responsible for transportation and will forfeit camp fees.

Choose one option (required)

I Agree (By checking this box, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, and agree to the terms of the attached Release and Waiver of Liability. I understand that checking this box represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) I Disagree

Water Baptism – I give my consent for the summer camper, if under the age of 18, to participate in water baptism?

Choose one option (required)

I Agree (By checking this box, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, and agree to the terms of the attached Release and Waiver of Liability. I understand that checking this box represents my electronic signature and is the legal equivalent of my manual/handwritten signature.) I Disagree

A minimum $25 deposit is required for camps and retreats unless previously agreed upon with our Camp Coordinators Corey & Michelle McBee. Deposits need to be paid or arranged for 1 week prior to the first day of the camp or retreat. Camp Fee’s can be paid online or by check to the address below. Please send all emails to Camp_Coordinator@campkairoswa.com

Choose one option (required)

I will go to the Camp Kairos shop and pay the deposit or full registration I will send a check or make arrangements for the deposit and/or registration by giving details in the following box

If you have any requests, comments or special instructions (i.e. regarding payment, campers needs/wants, cabin mate requests, cabin leader requests, etc.) please leave those here.

Message

Parent/Guardian Signature (By entering my name in the following boxes, I confirm that I am the participant or the parent/legal guardian of the participant. I acknowledge that I have read, understand, agree to the terms of the attached Releases and Waivers of Liability. I understand that all the information I have entered on this application are honest and true to the best of my abilities. I understand that entering my name in the following boxes represents my electronic signature and is the legal equivalent of my manual/handwritten signature.)

First name

Last name

Date (MM/DD/YYYY)(required)

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