2018 YOUTHTOPIA REGISTRATION FORM FOR YOUTH

Youth Name *
Youth Name
Gender *
T-shirts are subject to availability if registration is not received by the deadline.
Camp Covenant *
• I will come to camp expecting to grow in my faith and in relationship with others, becoming a special part of the camp community. In order to do this, I covenant to follow all the rules and guidelines set by the Christian Church in Alabama Northwest Florida and any others set for this event. With this, I commit myself to the following: To be on time, attend and be attentive for all camp/conference activities and participate in them fully • Have fun and make sure everyone else has a great time • To respect each other regardless of age and to respect others’ feelings and thoughts • I will not go from adult to adult until I get the answer I want • Be myself and open to making new friends • Be inclusive at all times • Cooperate with the counselors, keynoter, director and other staff members at all times • Be respectful of God’s beauty in this special place and only leave footprints behind • To take all that I learn about God and share it with my friends, family and church.
Do you have any health problems? *
Are you currently under the care of a physician or psychologist? *
Do you expect to have any difficulty with normal event activities? *
Do you have any food or other allergies? *
Do you take any prescription medication? *
Should your child be allowed appropriate over-the-counter medications to be given as needed? *
In case of emergency, I hereby give permission to the physician selected by the camp director to hospitalize, order injections, anesthesia or surgery for the child named above in order to secure necessary, proper medical care. I understand that I will be contacted immediately in the event that something unforeseen happens requiring my attention. I release the YMCA-Hargis Retreat staff and management, camp directors and counselors, and the Christian Church (Disciples of Christ) in Alabama-Northwest Florida and its staff, from all responsibilities in case of sickness or accidents causing injury occurring during camp. I have provided proof of insurance to those in charge.
Photo Permission *
I hereby give permission for my child to be included in candid shots or group photos which may appear in flyers or on the Region's website.
Parent/Guardian's Name *
Parent/Guardian's Name
Parent/Guardian Number *
Parent/Guardian Number
Emergency Contact Number *
Emergency Contact Number
Payment Options *
$125 per youth/adult

Please click the Submit button above to complete your registration.  Once you have completed this final step, please mail your payment to the regional office or click the "Pay Online" button to continue to the online payment portal.   By registering for this event sponsored by the Alabama-Northwest Florida Region, you are agreeing to the terms of the REFUND POLICY.  If you have questions or encounter problems submitting your registration, please call Susan at 205-425-5245.