Youth Camper Information

Camper Legal First Name *

Camper Legal Last Name *

Camper Preferred Name

If different than legal name please input name. This name will be used on your name tag!

Parent Email *

**This is the email that will be used to send out all camp information.

Parent Phone Number *

**This is the phone number that will be used to send out all camp information.

Camper Phone Number

Camper Email

Gender *

Male

Female

Date of birth *

Address

Street Address *

City *

State *

Country *

Postal code *

Have you ever attended a Messiah Texas Winter Camp? *

Yes

No

Congregation/ Church

Congregational Leader

Parent/Guardian Information

Parent 1 Name *

Parent 1 Relationship *

Parent 1 Phone Number *

Parent 1 Email *

Parent 2 Name

Parent 2 Relationship

Parent 2 Phone Number

Parent 2 Email

Emergency Contact Info

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Medical Information

Do you have any allergies, chronic illness, or medical conditions? If yes, please answer the next question. *

Yes

No

Please list allergies, chronic illness or medical condition.

Do you use an inhaler or carry an EpiPen? *

Yes

No

Please list inhalers used or needs of your EpiPen.

Dietary Needs (Outside of Biblically Clean Diet)

We accomidate gluten free, dairy free, and vegetarian

Does the camper plan to bring any medications to camp? *

Yes

No

If yes, please list the medications.

Event: Messiah Texas Winter Camp January 16-19, 2026

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

No

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

Yes

No

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

Yes

No

Do you frequently suffer from pains in your chest: *

Yes

No

Do you have Diabetes: *

Yes

No

Have you had any operations or serious injuries: *

Yes

No

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

Yes

No

Do you have Epilepsy: *

Yes

No

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

Yes

No

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

Yes

No

Please explain any yes answers.

Do you carry family medical/hospital insurance? *

Yes

No

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 1pm on Friday, November 21st and fly out after 4 pm on Monday January 16th, if you need transportation from us.

We will charge fee of $50 per person for the shuttle. 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 19th to ensure your spot on the shuttle.

If you plan to drive to camp, we will be at Lakeview Methodist Conference Center (400 Private Rd 6036, Palestine, TX 75801).

Check-In will begin at 5pm Friday January 16th.

We will conclude the retreat on Monday January 19th at 11:30am.

Do you plan to fly in to Texas for Camp? *

Yes

No

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- Lakeview Methodist Conference Center does not contract with the individual. We have the camp reserved so all questions need to come through the Messiah Texas Team.

https://messiahtexas.com/policies

I, (participant/parent/legal guardian if participant is under 18 years old) authorize my child to fully participation in the Messiah Texas Go Fish Winter Camp 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

Payment

Collect Payment *

Youth Winter Camp Camper Late Registration

$325

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