Register Middler Camp Middler camp is for ages 11-15 with a cost of $245. Register before April 30, 2018 and get an early bird price of $210. 1 Personal Info2 Medical Info3 Payment Select a Camp & DateMiddler Camps 2019*Middler Camp 1 - June 17, 2019 to June 22, 2019Middler Camp 2 - July 22, 2019 to July 27, 2019Camper InfoName* First Last Date of Birth* Gender*FemaleMaleShirt Size*Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAddress* Address City State / Province Zip Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Desired Cabinmate (Full Name)If possible, I would like the below person to be my cabinmate (optional). He/She must be the same age and must have requested you as well. Requests outside of this guideline may not be honored.Activity ChoicesSelect your top 4 desired activities in order of preference. You will be placed in 2 or 3 activities.Activity Choice #1*ArcheryBikingCanoeingCraftFishingHorsesRiflerySwimmingActivity Choice #2*ArcheryBikingCanoeingCraftFishingHorsesRiflerySwimmingActivity Choice #3*ArcheryBikingCanoeingCraftFishingHorsesRiflerySwimmingActivity Choice #4*ArcheryBikingCanoeingCraftFishingHorsesRiflerySwimmingParent/Guardian InfoName* First Last Email* Enter Email Confirm Email This is also where your registration information will be sent.Cell Phone*Home PhoneWork PhoneRelationship*MotherFatherLegal GuardianOtherRelationship to Camper* This person will pick up camper on Saturday Add another parent/guardian Parent/Guardian Info 2Name* First Last Cell Phone*Home PhoneWork PhoneRelationship*MotherFatherLegal GuardianOtherRelationship to Camper* This person will pick up camper on Saturday Add another parent/guardian Parent/Guardian Info 3Name* First Last Cell Phone*Home PhoneWork PhoneRelationship*MotherFatherLegal GuardianOtherRelationship to Camper* This person will pick up camper on Saturday Saturday Pickup PersonName* First Last Cell Phone*Church InfoChurch NameChurch Location City State PastorGroup Leader Insurance InfoProvider NamePolicy NumberGroup NumberHealth InfoMedical Conditions*Are there any health or behavioral conditions, or other medical concerns that Cedine should be aware of for your child? Asthma Other None DescriptionProvide detail about any of the above conditions.Allergies* Bee Stings Aspirin Nuts Hay Fever Penicillin Sulfa Other None Known OtherDescribe your allergies and reactions.Medications Taken RegularlyAny and all medications sent with a camper must be in original containers, or will not be administered.Please indicate any special needs, comments or requests in the box below.Copy of Insurance Card & Immunization RecordsA copy of the applicant's insurance card and a copy of the applicant's immunization records must be either submitted with this application, sent to us by mail to: 333 Cedine Camp Road, Spring City, TN 37381, or emailed to us at email@example.com. Please include your child's full name and the name and dates of the camp they are attending. Drop files here or Accepted file types: jpg, gif, png, pdf. AgreementParent/Guardian Authorization*The above information is correct to the best of my knowledge. He/she has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp health care staff to order X-rays, routine tests, treatment and necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give my permission to the doctor selected by the camp health care staff to secure and administer treatment, including hospitalization for my above-named child. I further release Cedine from all liability beyond the accident insurance carried by the camp. Furthermore, I understand that pictures will be taken during my child’s time at camp, and I give my permission for the use of such pictures containing my child’s likeness (and/or my likeness) for the promotion of Cedine’s camp or conference ministry. I agree to the terms above Cell Phone/Electronics Policy Agreement Form*In this technology age it is difficult for you and your child to not be in contact via cell phone. Camp is a unique environment. We are trying to help youth develop life skills at camp including independence and self-reliance. Oftentimes homesickness, which is a normal part of a week at camp, can be worsened by talking to mom and dad. We respect and appreciate the wonderful relationship youth and families have, but if your campers are to enjoy the camp fully they must be able to develop this independence. Campers are not allowed to bring cell phones or any other electronic devices to camp. If a cell phone or other electronics are brought with a camper they must be turned into the Camp Office upon arrival. Campers do not have access to camp phones. If there is an emergency or we are concerned about the youth’s well-being, parents will be contacted. I understand that I am not to bring a cell phone or other electronics to camp. I understand that campers are not to bring cell phones or other electronics to camp and agree to the above terms Camper Agreement* I understand and agree to abide by all the camp policies and any restrictions my parents have stated. Refund and Transfer Policy*Refunds or Transfers to another camp must be made at least 14 days before the registered camp begins. The payments are transferable to another camp this year or next year depending on availability. You may transfer payments to an unregistered person of the same gender if you are unable to attend. No payments may be transferred to a person who is already registered. If you do not notify us at least two weeks prior to the camp, your deposit is not refundable or transferable. I have read and understand the refund and transfer policy PaymentSelect Amount to Pay*Since it's before January 1, 2018, you can pay the 2017 early bird price for 2018 camps if you pay in full.Pay in Full ($40 Off) - $205.00Pay a Deposit - $75.00Select Amount to Pay*Since it's before April 30, 2019, you get an early bird discount.Pay in Full ($35 Off) - $210.00Pay a Deposit - $80.00Select Amount to Pay*Pay in Full - $245.00Pay a Deposit - $80.00 Request transportation to the camp (from Atlanta, GA only) - $75.00 Van Transportation Request Price: $75.00 If you have a coupon code, enter it here Cedine verifies coupons for each registration. If you are using a coupon without authorization, you will be responsible for full payment of fees.Credit Card Info American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name Total $0.00 Your credit card will be charged when you click submit.