1. CAMP LOCATIONS
Mauldin Camps - 306 Monroe Drive, Simponsville, SC 29681
Pee Dee Camps - 4533 Youth Court, Marion, SC 29571
PLEASE NOTE
Applications are accepted on a first come, first-serve basis. It is possible for a camp to be completely full and unable to
accept any more campers. Room assignments are made with approximately 10 campers and one counselor per group. Late
registrants must understand some rooms may already be filled. Every effort will be made to place friends together in
the same room, but the only way to ensure this is to register early. Remember, camp is a great experience regardless
of the room assignment received.
Pre-Registered Campers will receive an acceptance letter.

2. 2011 Youth Camper’s Application OFFICE USE ONLY
Rush to: Church of God Youth Camp
P.O. Box 309, Mauldin, SC 29662 Postmarked
www.sccog.com Camp Fee $
Amt. Enclosed $
Balance Due $
1. Last Name_________________________ 2. First Name__________________________
Computer #
3. Check one: Boy Girl 4. Date of birth _____/_____/_____ 5. Age _____ Camp Choice
Assigned To
6. Phone # ( ______ )________________ 7. Date of last Tetanus Shot _____/_____/_____ Confirmation
8. Email Address___________________________________________________________
Camp Fees
9. Mailing Address _________________________________________________________
Early Bird fee - $90.00
10. City___________________________ 11. State_____________ 12. Zip____________ ($45.00 deposit
13. List all pre-existing medical conditions and medications you must take. There must be a postmarked by May 15th
pharmacy label and directions on the prescribed medication._______________________ $45.00 due at registration)
_______________________________________________________________________
After May 15th & Walk-In
14. Medical Problems/Allergies or Handicaps. ____________________________________ - $110.00
15. Church_______________________________ 16. Pastor________________________
Deposits are non-refundable
17. Room mate preference____________________________________________________ nor transferable.
18. This is my _______ year at camp. I understand that camp maintains a Christian standard for conduct, dress, and sign my
name hereby promising to abide by all rules and policies and submit to those in authority during my stay.
19. Camper’s Signature__________________________________ 20. Pastor’s Signature_______________________________
21. Check The Camp You Will Attend - Errors Occur Frequently!
Mauldin Camps Pee Dee Camps
Ministry Camp (ages 13-18) June 13-17 Mini (ages 6-9) July 5 - 8
Mini camps begin on
Senior (ages 15 - 18) June 27 - July 1 Senior (ages 14-18) July 11 - 15 Tuesday at 3:00 p.m. and
Mini (ages 6 - 9) July 5 - 8 Junior (ages 10-13) July 18 - 22 end on Friday at 9:00 a.m.
Intermediate (ages 10 - 11) July 11 - 15
Junior (ages 12 - 14) July 18 - 22
22. Camp Tuition - I have enclosed $_______________ (Make check payable to: Youth Camp)
23-31 PARENT/GUARDIAN MUST COMPLETE BEFORE APPLICATION WILL BE ACCEPTED!
23. I hereby give my permission for my child to participate in any and all activities of the Church of God Youth Camp, and
waive all claims to injury or loss of property arising out of the activities against the leaders of this camp, the other participants,
and the Church of God Executive Offices of South Carolina and/or International. Parent/Guardian Initial Here
24. I understand that the Camp Insurance Policy provides secondary coverage, and I provide primary coverage for my child. I accept
financial responsibility for medical costs beyond limits of camp policy stated here: Medical & Hospital $2500, Dental $300,
eyeglasses are not covered if damaged or lost. All claims must be filed within the year of the accident.
Parent/Guardian Initial Here__________
25. If I cannot be reached in an emergency situation, you 28. Parent/Guardian Name_________________________________
have my permission for qualified medical
professionals to treat my child. 29. Day Phone # (___)_________ Night # (___)____________
Parent/Guardian Initial Here__________
30. Insurance Company Name _____________________________
26. ___________________________________
Parent/Guardian Signature Required 31. Policy # ____________________________________________
27. Today’s Date________________________ 32. Parent E-mail_________________________________________