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Rejuvenate 2026 Registration (1)

Please complete this form to register for Rejuvenate

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Step 1 of 5

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Contact Details

Name*

First Last

Leaders Code

Date of Birth*

Rejuvenate caters for unmarried young people aged 14-30 years old.

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Age (from DOB)

Gender*

Please indicate as to whether you are in a relationship with someone who is also planning on attending Rejuvenate?*

Yes

N/A

Email*

Please note that your email address will be added to our Mailchimp database so we can send you camp updates.

Enter Email Confirm Email

Unique ID

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Date

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent's/Guardian's Contact Details

Parent's Name*

First Last

Parent's Email*

Enter Email Confirm Email

Parent's Phone*

Medical Treatment Authorisation Form

Minor

Minor's Full Legal Name*

First Last

Address*

Street Address Address Line 2 City Region Postcode Country

Date of birth*

Gender*

Parent / Legal Guardian's Phone

Information for Medical Treatment

Physician’s Name and Location of Practice:*

Physician’s Phone Number (if known):*

Allergies to Medications*

Other Allergies*

Please note ALL conditions for which the child is currently receiving treatment:*

Will your child be taking any prescription medication during camp?*

Yes

Please list the prescription medication your child will have with them at camp and the time and frequency at which they require to take it.

Due to your child being a minor, and staying in cabins with other minors, we will require this prescription medication to be in the care of one of our Directors, Jessamae Hampson, for the duration of camp. Your child can see Jessamae at the appropriate time of day to take their medication.

Please note any other significant medical information:

AUTHORISATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

We would request you designate one of our Directors Team (Isaiah Smith, Sarah Smith, Joshua Mills, Hannah Mills, Ricky Hampson, or Jessamae Hampson) as the ‘designated adult’ for this form. If your child has a sibling or very close friend over the age of 18 years you would rather designate, you are free to do so.

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorisation and consent for the below listed adult (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorise the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorisation is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.*

Please enter the name of your chosen designated adult below: (We would request you designate one of our Directors Team (Isaiah Smith, Sarah Smith, Joshua Mills, Hannah Mills, Ricky Hampson, or Jessamae Hampson) as the ‘designated adult’ for this form. If your child has a sibling or very close friend over the age of 18 years you would rather designate, you are free to do so.)

Dates this authorisation is effective from and to:*

Rejuvenate dates are 12 July 2026 to 18 July 2026

Parent / Legal Guardian's Full Name*

First Last

Parent / Legal Guardian's Signature*

Register here!

Rejuvenate 2026 Registration (1)

Contact Details

Parent's/Guardian's Contact Details

Medical Treatment Authorisation Form

Minor

Information for Medical Treatment

AUTHORISATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

Leaders Questions

Event Details

Dietary and health

Sponsor a camper

Worship team

Payment Details

Register here!

Rejuvenate 2026 Registration (1)

Contact Details

Parent's/Guardian's Contact Details

Medical Treatment Authorisation Form

Minor

Information for Medical Treatment

AUTHORISATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

Leaders Questions

Event Details

Dietary and health

Sponsor a camper

Worship team

Payment Details

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