Please provide the following information:

* indicates required information

Select Type of Application:	Camper    Counselor  ( See "Counselor Agreement" below)
First Name:	*
Last Name:	*
Street Address:	*
City:	*
State:	*
Zip Code:	*
Date of Birth:	*
Present School Grade:	*   (grade 1-12 only--needed to determine class grade level)
Select Gender:	Male Female *
Your Pastor's Name:
Your Local Church:
Your Home Phone:	* (if none, write "none")
Your Work Phone:	* (if none, write "none")
Your Cell Phone:	* (if none, write "none")
Your Email address:	* (if none, write "none")
Select Age Group:	Preschool Junior Teen Adult *
Emergency Contact Name:	*
Emergency Contact Number:	*
Medical Insurance Company:	* (if none, write "none")
Group Plan Number:	* (if none, write "none")
Primary Care Physician:	* (if none, write "none")
Local Hospital Preference:	Arkansas Baptist Hospital Arkansas Heart Hospital Childrens Hospital Doctors Hospital St. Vincent Hospital UAMS VA Hospital Other (Please specify in Medical Information Box below) *
Medical Information #1:	Allergies  (List in the box provided below)
Medical Information #2:	Special diet / Food (List in the box provided below)
Medical Information #3:	List Medications (List in the box provided below)
Medical Information #4:	Other Medical Facility (Please list in the box provided below)
Detail Medical Information:

 

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Adult Emergency Medical Consent and Release (EMCR):

As an adult camper I authorize the staff of the Arkansas Winter Family Retreat to arrange emergency medical care to preserve my health and well-being.  I release the Arkansas Winter Family Retreat staff and the facility from any liability from any such decision or injury that occurs during camp.  I further agree to assume responsibility for any cost associated with medical care.

As the parent/guardian of the above camper, I authorize the staff of the Arkansas Winter Family Retreat to arrange emergency medical care to preserve the health and well-being of my child.  I release the Arkansas Winter Family Retreat staff and the facility from any liability from any such decision or injury that occurs during camp.  I further agree to assume responsibility for any cost associated with medical care for my child.

Please indicate your agreement to this statement by clicking the circle below with you mouse. *

As the adult camper or the parent/guardian of the above camper, I hereby certify that I  have read and agree to the Emergency Medical Consent and Release statement.

* Counselor Agreement:

If you are under the age of 18 and apply to become a Counselor, permission must first be granted by Dr, Jim for you to serve as a Counselor.

I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE.  I FURTHER CERTIFY THAT I HAVE NEVER BEEN CONVICTED OF CHILD ABUSE OR SIMILAR MISCONDUCT RELATING TO CHILDREN.  I HAVE READ THE STATEMENT OF FAITH AND POLICIES OF AWFR AND AGREE TO COMPLY WITH THESE POLICIES.  I WILL SUBMIT TO THE AWFR CHAIN OF COMMAND AND TAKE MY RESPONSIBILITY SERIOUSLY AS A JOB TO BE DONE “AS UNTO THE LORD”.

Please indicate your agreement to this statement by clicking the circle below with you mouse. *

I hereby certify that I  have read and agree to the Counselor Agreement above.

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Notice to parents/guardians: Campers must be picked up only by parent, guardian or person given written authorization by parent/guardian.

*****          IMPORTANT          ***** The moment you click on the "Submit Form" button you will be shown a "Form Confirmation" page. Please PRINT two (2) copies of the Form Confirmation.  Keep one copy of the Form Confirmation for your records.   Sign the other in the applicable "Signature" area.  Within one week from the time of registering on-line, please submit the signed "Form Confirmation" to Dr. Jim by mail with a check for at least $32.00 toward your total $132.00 tuition fee. Sending this amount   $   Thank you.