Teen Leader (Preferred) First Name *

Teen Leader Last Name *

Gender * Select ...MaleFemale

Age * Select ...16171819202122232425

Current Grade * Select ...1112College Age

Email (All camp communication and information will be sent to this email) *

Mother's First Name (If not applicable, type none.) *

Mother's Last Name (If not applicable, type none.) *

Mother's Cell Phone Number (If not applicable, type none.) *

Mother's Email (If not applicable, type none.) *

Father's First Name (If not applicable, type none.) *

Father's Last Name (If not applicable, type none.) *

Father's Cell Phone Number (If not applicable, type none.) *

Father's Email (If not applicable, type none.) *

Street Address *

City *

State *

Zip Code *

Home Phone Number (Include area code.) *

Teen's Cell Phone Number (Include area code.) *

Home Church

School Teen Attends *

How many years have you attended KOV as a Teen Leader? * Select ...None123456

Adult T-Shirt Size * Select ...Adult SmallAdult MediumAdult LAdult XLAdult XXL

I am interested in helping with special needs campers * Select ...YesNo

Name of Emergency Contact (Father and mother will be contacted first - please list someone who is not the father or mother.) *

Relationship with camper of emergency contact *

Day time phone number of emergency contact *

Cell phone number of emergency contact *

Primary Contact * Select ...FatherMotherEmergency Contact

Allergies (If not applicable, type none.) *

Medications (If not applicable, type none.) *

My teen has permission to participate in all KOV events and field trips. I give my consent for my teen to be photographed as a part of KOV programming and non-profit promotions. In the event that my teen needs medical attention during KOV, I give permission for the Ministry Staff to administer medical treatment or admit to a hospital for emergency treatment. I further agree to hold harmless and release from liability Southgate Church, its ministers, and anyone acting on behalf of KOV for any and all injuries sustained while at KOV. * I Agree

Medical Release (I give my permission to administer over the counter medication.) * Select ...YesNo