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Camps at Golden Bell sponsored by the CO Conference of the Church of God 2012

Campers Name:__________________
Gender __ M __ F
Check Camp
____ Trailblazer Entering or Exiting Grades 1-2 - July 11-13
Registered for:
____ Itch-ee-ow-ee Entering or Exiting Grades 3-6 July 23-27
____ Velocity Entering or Exiting Grades 7-12 June 25-29
Birth Date __________________ Last Grade Completed ________________________
Address ______________________________________________Email______________________
City____________________________ State _____ Zip ________________
Church _____________________________Pastors Name ________________________________
1. Parent/Guardians Name __________________________________________________________
Address (if different) _______________________________________________________________
Phone: home _______________ work _________________ cell ___________________________
2. Parent/Guardians Name _________________________________________________________
Address (if different) ______________________________________________________________
Phone: home _______________ work _________________ cell ___________________________
Alternate Emergency Contact ________________________________________________________
Address: ________________________________________________________________________
Phone: home _______________ work _________________ cell ___________________________
Person(s) other than parent/guardian authorized to pick up child from camp __________________
________________________________________________________________________________
Person(s) other than parent/guardian not authorized to pick up child from camp ______________
________________________________________________________________________________
Family Pack, 1st family member pays full price, additional members get $25 off.
Name of 1st family member _________________________________________________________
Bring-a-Buddy, Bring a friend whos never been to Golden Bell and one of you gets $50 off,
2nd Buddy $50 off, 3rd Buddy you come Free!
1st Friends Name _____________________________
2nd Friends Name _____________________________
3rd Friends Name _____________________________
Who gets the discount? Me/My friend.
Requested Cabin-mates (we try to match by age) ________________________________________

Parent or Guardian Authorization Required for participation.

All information on this form is correct and complete.


I give permission for my child to participate in all on or off site camp activities, including transportation, except as noted, to be provided routine health
care, and to be given medication authorized by my childs health care provider or the licensed medical provider selected by the camp. I give permission to
the physician selected by the camp to order x-rays, routine tests and treatment for the health of my child. If I cannot be reached in an emergency, I give
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child. I also give permission for
my childs photo to be used in future promotional materials, brochures and videos. I agree to hold harmless for loss or damage and agree not to sue or
bring any action whatsoever against Golden Bell Camp and Conference Center, its agents, servants, & employees on account of injury to my child while
participating in camp activities. I am fully aware of the inherent hazards and risks involved in camp activities, and assume all risks of loss or injury. I
understand that Golden Bell provides secondary insurance only, and that Golden Bell is not responsible for personal belongings brought to camp. Golden
Bell is an equal opportunity service provider. Golden Bell is a permittee of the Pike National Forest.

Signature ____________________________________ Date _______________

Horseback Riding Permission and Release

(must be signed before child will be allowed to ride) I, the undersigned, agree
to hold Golden Eagle Outfitters, Inc. and/or Golden Bell Camp & Conference Center harmless for any and all damages which may occur as a result of my
child participating in equine activities. I understand that under Colorado law, equine professionals are not liable for any injury to or death of a participant
in equine activities resulting from the inherent risks of equine activity, pursuant to 13-21-120 Colorado revised statutes.

Parent/Guardian Signature _______________________ Date _______________

Physical Exam signed by a licensed physician or nurse practitioner and dated no more than 24 months prior to camp is
required for your child to attend camp. Please send with Registration or mail copy no later than 2 weeks
prior to camp.

(OVER)

Campers Health Information

Please attach a note with any special concerns. Please notify camp if your
child is exposed to any communicable disease during the 2 weeks prior to camp.

Campers Name: _________________________


Health Problems/ Surgeries /Illnesses Activity Restrictions
_______________________________________________________________________________________________
Drug/ Food Allergies/ Allergic Reactions
_______________________________________________________________________________________________
Regular Medications/ Medication Restrictions
_______________________________________________________________________________________________
Medical Insurance Company Name, Address & Phone Policy & Group Numbers
____________________________________________ _________________________________________________
Special Dietary Considerations
_______________________________________________________________________________________________
Dates of Last Immunization Boosters: MMR _____ DPT _____ Tetanus _____

Trailblazer Camp
Registration received by April 20:
Registration received April 21-June 15:
$ 124
$ 144
-65 Church of God Grant
-65 Church of God Grant
$ 59
$ 79
Late Registration after June 15: $179 sent directly to Golden Bell
Itch-ee-ow-ee Camp
Registration received by April 20:
Registration received April 21-June 27:
$ 229
$ 259
-85 Church of God Grant
-85 Church of God Grant
$ 144
$ 174
Late Registration after June 27: $294 sent directly to Golden Bell

Questions?
Contact Tami Mills
303-987-2415
Millsntrm4@msn.com

Velocity Camp
Registration received by April 20:
Registration received April 21-May 30:
$ 269
$ 299
-115 Church of God Grant
-115 Church of God Grant
$ 154
$ 184
Late Registration after May 30: $334 sent directly to Golden Bell
Camp Fee see above cost minus Church of God Grant
8 X 10 Camp Picture
$
Camp DVD
$
Horseback Riding (Itch-ee-ow-ee or Velocity)
$
Whitewater Rafting (Velocity Only)
$
Family Discount see 1st page registration form
$
Bring a Buddy Discount see 1st page registration form
$
T-shirt please circle size:
Youth S M L
Adult S M L XL XXL
Total
$
Deposit Paid $
Balance Due $
Mail completed form and a check made payable to Golden Bell Camp to:
The full amount is appreciated, however, $75 deposit is required and
the balance may be paid on arrival at camp. *Exception: Trailblazer paid

$ __________
__________
8.00 (optional)
__________ 15.00 (optional)
__________ 33.00 (optional)
__________ 36.00 (optional)
__________ -25.00
__________ -50.00, -100.00, free
free
__________
__________ ($75 required*)
__________

Tami Mills
542 S. Deframe
Ct.
Lakewood, CO

before April 20 is $59.


Golden Bell Camp and Conference Center
380 CR 512
Divide, CO 80814

voice: 719-687-9561
www.goldenbellccc.org

fax: 719-687-5400
email: info@goldenbellrocks.com