Camper Application - Hebrew Roots - Teens With A Mission

Name*

First Last

Gender*

Male
Female

Current Age*

Date of Birth*

MM

DD

YYYY

Home Congregation

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Email Address*

Do you play an instrument or lead dance?*

I play an instrument
I lead dance
I can play an instrument and/or lead dance
No, I do not play an instrument or lead dance

Name of Parent/Guardian*

First Last

Parent/Guardian Main Contact Phone*

Parent/Guardian Work Phone

Parent/Guardian Cell Phone

Parent/Guardian Email Address*

Other Emergency Contact & Phone Number(s):

Please list any medical conditions or health concerns that our staff should be aware of:

Please list any allergies to food, medication, animals, or plants/insect bites:

Please list any diet restrictions:

Please list any prescription medication being taken:

Media Release Permission*

I hereby authorize HRTWAM (Hebrew Roots Teens With A Mission) personnel to take my child’s photograph/video during camp or their participation in any teaching/activity sessions. I hereby release the photograph/video to HRTWAM (Hebrew Roots Teens With A Mission) in promotional materials or other official publications:

As Parent/Guardian I DO authorize HRTWAM staff
As Parent/Guardian I DO NOT authorize HRTWAM staff

Parent Release Permission*

I hereby authorize the HRTWAM (Hebrew Roots Teens With A Mission) to secure medical services as may be deemed necessary for my child’s health and safety. I will be informed immediately of any medical services that are required. I release HRTWAM (Hebrew Roots Teens With A Mission) and anyone connected with it from any and all liability claims resulting from illness, accident, and/or misfortune:

As Parent/Guardian I DO authorize HRTWAM staff
As Parent/Guardian I DO NOT authorize HRTWAM staff

Camper Essay*

Please write a paragraph for us, telling us about yourself, your personal walk with our Creator, why you wish to participate in HRTWAM Camp mission’s trip, what you are hoping to accomplish, and how you hope to benefit from it:

Will You Need A Sponsor?*

The cost of the camp lodging, meals, and activities for all the teen campers is $650. Each camper is also responsible for the cost of airfare to and from San Jose, Costa Rica.

No, I do not need a sponsor to help cover my Mission Trip costs
Yes, I will need a sponsor to help cover my Mission Trip costs

Name

This field is for validation purposes and should be left unchanged.