Application

Applicant Information

Your First Name (required)

Your Last Name (required)

Your Email (required)

Your Date of Birth

Your Gender
 Male Female

Your Address Information (required)



Applicant under the age of 18?
 Yes No

T-Shirt Size (required)
 Small (34-36) Medium (38-40) Large (42-44) XLarge (46-48) XXLarge (over 48)

Camp Cost includes all food, lodging, mission T-shirt, training materials and transportation to and from
base camp to and from the mission field.

Camp Cost: $300.00
Deposit $25.00*
Balance owed $275.00**

*Note on “Deposit”: Make $25.00 check or money order payable to Word in the Street. Your deposit
must accompany this application in order for you to be considered for camp. The deposit is non-
refundable, as long as you are accepted for camp. If you are not accepted for camp due to space
limitations or other reasons, your deposit will be refunded to you. Changing your mind about coming to
camp is not grounds for refund of deposit.

**Note on “Balance Owed”: Final payment must be
received by Word in the Street no later than two weeks
prior to camp. Please be prompt with your payment,
since many camp expenses must be paid in advance.
Late payment will be grounds to allow someone else on
a waiting list to take your place at camp.

How Did You Hear About Us?

What do you hope to gain/give/learn from Word in the Street Mission experience? (required)

Consent and Release (required):
Does the applicant have any conditions that limit or prohibit applicant’s physical activity?
Circle either: YES or NO If yes, please explain below. If no response is given, Word in the
Street will assume applicant can engage in all Word in the Street activities.
 Yes No
If Yes please explain:

For all applicant’s: I grant permission for the camp or sponsor to use any video images taken of
the applicant at any camp event in their publications.
For parents/guardians of minor applicants (those under 18 years old): I give Word in the Street
permission to have my child participate in all camp activities, unless specifically limited above. I
give my permission for my child to be transported off the camp property for all camp supervised
activities.

(required)

Applicant Process: Applications will be reviewed as they are received with the $25.00 deposit. If
accepted, a letter and information packet will be sent to the applicant giving more details about the
camp, activity schedule, transportation, what to bring, fundraising, etc.

Mail Deposit to:

Word in the Street
P.O. Box 54481
Cincinnati, Ohio 45254

Insurance Information

Insurance Company (required)

Group#

Insurance Company Address Information



Insurance Subscriber's Information


Insurance Co. Phone Number

Employer's Address Information



Medical Information

Medical Issues: (disclosure will only be shared with group leaders or health care professionals, if needed)

Please list any medical problems you have:

Are you under the care of a physician due to physical conditions we may need to know about?
If so, explain:

Do you have any physical limitations of chronic concerns that limit your activity? If so, explain:

Are your immunizations up to date?
 Yes No

List (with dosage) any prescription medication you take on a regular basis:

List any allergies

When was your last tetanus vaccine?

Emergency Contact Information:

List the name of an emergency contact

Phone

Alternate Phone

Relationship to Applicant

Mother's Name

Mother's Phone Number

Father's Name

Father's Phone Number

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