Youth Camper Information

Youth Camper First Name *

Youth Camper Last Name *

Youth Camper Preferred Name *

Youth Email *

Youth Phone *

Youth Gender *

Male

Female

Youth Date of Birth *

Youth Camper T-Shirt Size *

Youth Camper Hoodie or Jacket Size *

Address

Street Address *

City *

State *

Country

Postal Code *

Have you attended Messiah Texas Youth Camp before? *

Yes

What congregation/church do you attend? *

Who is your congregation leader? *

Parent Information

Parent 1 First Name *

Parent 1 Last Name *

Parent 1 Relationship *

Parent 1 Phone *

Parent 1 Email *

Parent 2 Name *

Parent 2 Relationship *

Parent 2 Phone Number *

Parent 2 Email *

Emergency Contact First Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Medical Information

Do you have any dietary restrictions other than Biblically clean?

Gluten Free

Dairy Free

Vegetarian

Event: Messiah Texas Winter Camp January 15-18, 2027

The proposed activity provided by Messiah Texas requires participation in physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases.

Therefore, all participants must be free of medical or physical
conditions which might create undue risks to themselves or any others who depend on them. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination.

Have you had or do you currently have any heart problems: *

Yes

Has a doctor ever told you that you have high blood pressure: *

Yes

Do you have arthritis, joint, or back problems : *

Yes

Do you often feel faint or have spells of severe dizziness: *

Yes

Do you frequently suffer from pains in your chest: *

Yes

Have you had any operations or serious injuries: *

Yes

Do you have any chronic recurring illness or communicable diseases: *

Yes

Are there any activities to be limited by a physician's advice: *

Yes

Do you have Diabetes: *

Yes

Are you allergic to any medicines, insects, or pollens: *

Yes

Do you have Epilepsy: *

Yes

Do you use an inhaler or carry an epipen? If yes, please explain below. *

Yes

Are there prescribed medications currently being taken (please explain below) *

Please explain any yes answers.

Any other health related information.

Do you carry family medical/hospital insurance? *

Yes

Policy Holder:

Policy Number:

Carrier:

Carrier Phone Number:

Please upload a copy of your medical insurance

Travel Information

If you plan to fly into camp we ask that you fly in before 2pm on Friday, January 15th and fly out after 4 pm on Monday January 18th, if you need transportation from us.

We will charge fee of $100 per person for the shuttle, $50 each direction. After registering, you will receive an email with information of how to sign up and pay for the shuttle. You must give us your flight information by January 1st to ensure your spot on the shuttle.

If you plan to drive to camp, we will be at JAMA Global Campus (22392 FM Rd 16, Lindale, TX 75771).

Check-In will begin at 5pm Friday January 15th.

We will conclude the retreat on Monday January 18th at 11:30am.

Do you plan to fly in to Texas for Youth Winter Camp 2027? *

Yes

Maybe

Acknowledgements

Please check mark each of the below policies verifying you have read and acknowledged them.

I agree I have read the In and Out Policy.

I acknowledge I have read the Refund Policy as stated on our website and agree to the terms and conditions. I acknowledge my payment must be completed in order to complete the registration. If I do not complete the payment, I will have to start at the beginning.

Contact Messiah Texas Directly- JAMA does not contract with the individual. We have the camp reserved so all questions need to come through the Messiah Texas Team.

I, (participant/parent/legal guardian if participant is under 18 years old) authorize my child to fully participation in the Messiah Texas Winter Camp 2027 and related activities. I understand the activities are not without some inherent risk of injury.

In consideration of my child's right to participate in this activity, I agree to release, waive, discharge, agree not to sue, and to hold harmless for any and all purposes Messiah Texas and their officers, employees, agents, and volunteers. I release Messiah Texas from any and all liabilities, claims, or injuries, including death, that may be sustained while participating in this activity, including traveling to, from, and for the activity, or while on premises owned or controlled by Messiah Texas, including injuries sustained as a result of the negligence of Messiah Texas. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of Messiah Texas. I further agree to indemnify and hold harmless Messiah Texas for any loss, liability, claim, or injury caused by me (my child) while participating in this activity, including traveling to, from, and for the activity, or while on premises owned, leased, rented, controlled, or operated by Messiah Texas.

I also give my permission for me (my child) to receive any emergency medical treatment by a healthcare professional, including emergency medical transportation, which may be required for injuries sustained by me (my child). I agree to indemnify and hold harmless Messiah Texas for any costs incurred to treat me (my child), even if a Messiah Texas officer, employee, agent, or volunteer has signed hospital documentation promising to pay for the treatment.

Furthermore, I (my child) agree to follow all instructions and procedures in order to maintain a maximum level of safety.

Parent Legal Guardian Name: (If Participant is under 18) *

Parent/Legal Guardian Signature *

Clear

Todays Date *

Payment

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By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from [BUSINESS NAME] at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.