Registration – Chautauqua Hills Camp

Register for 2024 summer camps by completing this form and waiver. You can submit your deposit to 1788 Old Chautauqua Rd., Gerry, NY 14740. If you prefer, you can also download the 2024 brochure and submit your registration and waiver with your deposit by mail.

Camper Information

Name

Age

Grade (In the Fall)

(required)

Male

Female

Address

City

State

Zip

Phone

Cell Phone

Medical Information

Emergency Contact

Emergency Contact Phone

Are there any allergies or special needs that your child has? i.e. bee sting allergies, bed-wetting, sleep-walking, food allergies

Does your child take any medicine?(required)

Yes

If yes, what and how often:

Insurance Policy Number

Name on Insurance Policy

Family Doctor

I permit my child to participate in all sports, hiking, and other camp activities. I certify that my child has had a physical exam within the last 12 months by a physician and is physically able to do all activities with the exception of:

In the event of an emergency, I (parent/guardian) hereby give permission to the physician selected by the Camp Director to hospitalize, to secure proper treatment for, and to order injections, anesthesia, or surgery for my child.

2024 Summer Camps

Please check the schedule for camp week your child would like to attend. In order to reserve space for your child and to receive the early registration discount, please make sure we have your deposit in by June 15.

Camp Schedule and Pricing

Camp Week	Total Cost for this Camp Week	Subtract Non- refundable Deposit (Send in now)	Subtract $10 Discount if Deposit is Received by June 15	If doing Paintball Add Extra Fee of $10	Remainder Due Upon Arrival
Defender’s Retreat Grade 8 – Young Adult July 1–2	$30	– $15	N/A	+ $10	?
Youth Week 1 Grades 3–8 July 8–11	$65	– $25	– $10	N/A	?
Teen Week 1 Grade 6 – Grads July 15–18	$65	– $25	– $10	+ $10	?
Youth Week 2 Grade 3–8 July 22–25	$65	– $25	– $10	N/A	?
Guys Adventure Grade 6 – Grads August 2–3	$35	– $15	N/A	Included	?
Teen Week 2 Grades 6–12 August 5–8	$65	– $25	– $10	+ $10	?
Mission Trip Grades 8–12 August 14–17	$50	N/A	N/A	N/A	?
Youth Week 3 Grades 3–8 August 19–22	$65	– $25	– $10	N/A	?
Game Night Grades 6–12 August 30	$3	N/A	N/A	N/A	?
Extra Paintball Grade 9 – Adult July 13	$10	N/A	N/A	N/A	?
Extra Paintball Grade 9 – Adult July 27	$10	N/A	N/A	N/A	?
Extra Paintball Grade 9 – Adult August 10	$10	N/A	N/A	N/A	?
Extra Paintball Grade 9 – Adult August 24	$10	N/A	N/A	N/A	?

To reserve space for your child, please mail in your deposit as soon as possible. Add up the deposits for your selected camp weeks from the pricing above and mail a check to Chautauqua Hills Camp at 1788 Old Chautauqua Rd., Gerry, NY 14740.

Participant Agreement

Details

I acknowledge that participation in any of this year’s events, may involve risk to the Participant (and to the Participant’s parents / guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

With regard to events organized for minors, I also understand that the events this year will include participation by adults in children’s activities which also carries the potential for injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in this year’s events, the Participant (or parent / guardian if Participant is a minor) acknowledge and accepts the risks of injury associated with participation in and transportation to and from events.

The Participant understands that specific activities included in the events may include, but are not limited to, low ropes team building, zip-line, tree climbing, water sports such as swimming, boating, water slide, winter activities such as sledding, snow ball fights, large group games such as capture the flag, ultimate Frisbee, kickball, and nature activities such as sleeping in the tree bus, hiking and camp fires.

The Participant (or parent / guardian) accepts personal financial responsibility for any injury or other loss sustained during any event this year or during transportation to and from an event, as well as for any medical treatment rendered to the Participant that is authorized by Chautauqua Hills Camp / Ministries or its agents, volunteers, or any other representatives.

Further, the Participant (or parent / guardian) releases and promises to indemnify, defend, and hold harmless Chautauqua Hills Camp / Ministries or its agents, volunteers, or any other representatives for any injury arising directly or indirectly out of any event or transportation to and from an event, whether such injury arises out of the negligence of Chautauqua Hills Camp / Ministries, the Participant, or otherwise.

The Participant (or parent / guardian) gives consent to Chautauqua Hills Camp / Ministries to photograph and record images and sounds to be used in promotional materials.

The Participant (or parent / guardian) agrees to comply with camp rules and procedures and understands that failure to comply may result in the Participant being dismissed from the Activity without refund and agrees that transportation from the event will be the responsibility of the Participant (or parent / legal guardian).

I have read and agree to the Participant Agreement.

Youth Camper Agreement

Details

I understand the importance of, and will adhere to, camp safety regulations and the directions given to me by camp leaders so they can provide me and all campers with a safe, pleasant, and memorable camp experience. I will be sure to give all medications to the nurse. I understand that if I fail to follow camp rules, I may be sent home.

I have read and agree to the Youth Camper Agreement and reviewed with the youth camper.

Paintball Release of Liability Form

Note: Paintball is an optional add-on activity. All participants must be eleven (11) years of age or older to play paintball. These details must be read and signed before the participant is allowed to take part in any paintball event.

Details

In consideration of being permitted to participate in any way in the sport and activities of paintball under the auspices of Chautauqua Hills Camp/Ministries, I acknowledge, appreciate, and agree that:

The risk of injury from the activity and weaponry involved in paintball is significant, including the potential for permanent disability and death, and while particular protective equipment and personal discipline will minimize this risk, the risk of serious injury does exit; I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of those persons released from liability below, and assume full responsibility for my participation; and
I understand that the activities of paintball are physically and mentally intense. I understand the rules of play and will comply with rules and regulations. If I observe any unusual or unnecessary hazard during my participation, I will bring such to the attention of the nearest official as soon as practical; and,
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless Chautauqua Hills Camp / Ministries, the owners and lessors of premises used to conduct the paintball activities, their officers, officials, agents and/or employees/volunteers (“Releasees”), with repect to any and all injury, disability, death, or loss or damage to person or property, whether caused by the negligence of the releases or otherwise, except that which is the result of gross negligence and/or wanton misconduct.
I understand and agree that this Release of Liability Agreement covers each and every paintball activity and event in which I participate hereafter.

For Participants of Minority Age (under age 18 at time of registration)

This is to certify that I, as parent/guardian with legal responsibility for the participant, do consent and agree not only to his/her release of Chautauqua Hills Camp / Ministries and all other Releasees but also to release and indemnify the Releasees from any and all liabilities incident to his/her involvement in these programs for myself, my heirs, assigns, and next of kin.

I have read this Paintball Release of Liability and Assumption of Risk Agreement, fully understand it’s terms, understand that I have given up substantive rights by signing it, and sign it freely and voluntarily without any inducement.

Parent/Guardian’s Name as Signature

Dear Participant,

Even though we require waivers, we want to insure you that we in no way look on this as an excuse to be slack in safety at C.H.C. We are constantly monitoring and updating our safety procedures and equipment. If you have further questions, please let us know. Thank you for your help.

— Chautauqua Hills Camp / Ministries