Online Registration (Wichita Work Camp)

Online Registration

Welcome to the Registration Page. Online registration is now active and ready to use! From this page you can register and pay for Wichita Workcamp. You can use this form to register whether you live in-town or out-of-town. Make sure you complete the following steps:

1. Complete the form below accurately.
2. Make your payment online through PayPal. (You will automatically be directed once you submit your information)
3. Once we have your information & payment, you will receive a confirmation email within 48 hours.
4. This is an individual registration process. If you are registering a group, you will need to enter their information one at a time. ALL of your participants (adults, teens, sponsors, etc) should register.

Contact information Name

Address

City
State

Zip

Email

Sex
Male
Female

Date of Birth (mm/dd/yyyy)

Church you are attending with:

Current grade ('09-'10) or age group (pick one)

Cost Level

Participant Type

T-shirt size (adult size):

Experience Have you ever painted a house before?

Yes
No

I would like to purchase a copy of the Workcamp DVD. (please add $25 to your fee; DVDs will be mailed to your youth leader after Workcamp)
Yes
No

Medical Information Drug allergies, other allergies, health problems:

Name(s) of medication and when taken:

Date of last tetanus shot (mm/dd/yyyy)

You must have medical insurance to work at Wichita Workcamp. If you do not have insurance you may purchase a short term policy from a local agent.You may attach a copy of camper's insurance card if preferred, or fill out the information below.

Medical insurance carrrier:

Policy number:

Phone number:

Emergency Contact 1st person
Name
Relationship
Phone number(s):

2nd person
Name
Relationship
Phone number(s):

Release for Parent/Guardian of Worker Under 18

As parent or guardian of the above applicant,I hereby give my approval and consent to this application and therefore relieve any sponsoring congregation or Workcamp staff member from any and aIl liability for sickness, accidents, or injuries of any nature or cause whatsoever, while attending or traveling to or from Workcamp. I further give authorization for the camp director or any approved camp personnel to administer such acts of first aid as deemed necessary. Authorization is also given for approved staff members to transport campers to a doctor or emergency room of a hospital to secure theservices of a licensed physician. I further promise to utilize family insurance for any major medical care requiring hospitalization. I also consent to the use of any digital media in which my above named child may appear for promotion of Wichita Workcamp.

Parent/Guardian

Release for worker over 18

I hereby give my approval and consent to this application and therefore relieve any sponsoring congregation or Workcamp staff member from any and aIl liability for sickness, accidents, or injuries of any nature or cause whatsoever, while attending or traveling to or from Workcamp.I further give authorization for the camp director or any approved camp personnel to administer such acts of first aid as deemed necessary. Authorization is also given for approved staff members to transport campers to a doctor or emergency room of a hospital to secure the services of a licensed physician. I further promise to utilize family insurance for any major medical care requiring hospitalization. I also consent to the use of any digital media in which I may appear for promotion of Wichita Workcamp.

Worker

You MUST accept and digitally sign this form to submit your registration and continue to the payment page.

I agree to the above terms