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Diamonds in the Rough Jr. High Camp 2020 Application

*Last Name:
*First Name:
*Grade entering:
*Date of Birth:
Nickname if applicable:
*Insurance Company:
*Policy #:
*Home Address:
*Home Address:
*Home City:
*Home State:
*Home Zip:
T-Shirt Size:
Health History:

*Does your child have any physical limitations that will require them to sit out of or modify activities such as long hikes, swimming or sports that require a lot of running? :

There will be a head lice check at camp and anyone found with lice will be sent home. They must be free of all nits. (eggs) Please check you child now and treat them. We do not want to have to send anyone home!

Your specific answers will help us better prepare for your childís safety at camp


Allergies Description:

Indicate the date of immunizations. State law requires they all be up to date.

*Polio (OPV/IPV):
*Chicken Pox:

Contact person for emergency only

*Name :
*Family Doctor:

PLEASE HELP US BETTER UNDERSTAND YOUR CHILD BY BEING VERY SPECIFIC ABOUT WHERE THEY ARE AT EMOTIONALLY, SPIRITUALLY AND IN THEIR FAMILY LIFE. (Confidential between counselor, director, and the nurse) Your childís counselor will be much better equipped in understanding your child. This information is valuable for prayer time and preparation time. When your child comes to camp, the counselor has already gotten to know him/her through the application and by taking your child to the Father in prayer. (Feel free to attach an extra sheet if needed)

Your marital status:
Is your child adopted?:

Foster Child?:

Emotional traumas or psychological disorders? (please explain):
How does your child relate to kids their own age?:
Is your child dealing with any issues or trauma that cause him/her to be depressed or act out in anger, or is your child hyperactive?:
How does your child get along with authority figures?:
If your child desires to be water baptized do we have your permission to baptize them?:

Is your child comfortable with being away from home?:
One person your child would like to room with:


In the event of any emergency where medical treatment is required, I give my permission to the church staff or sponsor to obtain the services of a licensed physician. I/we release the River of God Church, its agents, employees and volunteer assistants from any liability whatsoever arising out of any injury, damage or loss which may be sustained by said person during the course of involvement with R.O.G. Church or Camp AoWaKiya. I understand that the River of God Church is a full gospel church and believes in and practices the gifts of the spirit, the laying on of hands, healing of the sick, and free expression during praise and worship. I/we certify that said child is able to participate and hereby consent to his/her participating in any approved church activities. I understand that some activities are paintball, zipline, flying squirrel, high ropes, rock climbing, swimming in Lake Michigan, dune rides, canoeing, marksmanship, archery tag, and similar physical activities that can cause injury.

PHOTO RELEASE: Photographs and video footage taken of my child as a result of participation in activities at Camp AoWaKiya/ R.O.G. Kidís Camp may be used in promotional materials or the website and social media.

*Signature of parent/guardian:
Motherís Name:
Motherís Phone:
Fatherís Name:
Fatherís Phone: