Fill out the application below and then click the submit button.

If you have any questions or would prefer to use a paper application through the mail, please call our office at 574-232-8523.

The application process may take 10 minutes or more and you will need to complete it at one time. You cannot save any information from the form to come back to.

General Information

Racial/Ethnic Identity: You are NOT required to answer this question.
Check any that apply





Parent/Caregiver Information

You must provide two unique additional emergency contacts. Emergency contacts must be adults. These must be different from the Parent/Caregiver information above
Emergency contacts/people who may signout and pickup the child:


Dates New for this summer: Pick-up is on Fridays at 7:30pm





Health History
Check all that apply




Parental Consent for Medicine Dispersal


Behavioral Expectations The Ray Bird Ministries staff expects that your camper will be able to perform the following:
  • Eat meals and assist with clean up on his/her own
  • Express herself/himself verbally and appropriately
  • Dress herself/himself and maintain personal hygiene


Angel Tree Sponsorship If your child currently has or had an incarcerated parent or lives with a child with an incarcerated parent, they may be eligible for a camp sponsorship through Angel Tree. Please fill out the information below to allow us to determine eligibility. Information will not be shared with child.





*Required fields for a Angel Tree Sponsorship

Limited Purpose Power of Attorney: Consent to Treatment of a Minor A. The undersigned hereby appoint Ray Bird Ministries and representative each to act alone, and delegate to each such person the power to consent on our behalf to all emergency treatment and/or medical care (except elective surgery) of the child named above determined to be necessary or desirable by our child's attending physician at the hospital. B. This Power of Attorney shall continue until revoked by the undersigned, or for eighteen (18) months after its date, whichever is earlier. Physicians or the hospital's medical staff may assume and rely that this authorization is currently in effect during such eighteen-month period unless notified. C. The undersigned certify that they have read this Power of Attorney (or had it read to them), and that they understand this Power of Attorney.

Photo Release and Follow Up I certify that photographs or videotape pictures of my child participating in Ray Bird Ministries' programs may be reproduced and utilized in promotional materials for the camp including social media. I certify that for purposes of following up on my child's camp experience, Ray Bird Ministries may release my child's name to a church or other youth organization.

If you have a concern about your child's picture being used for the above stated purposes, please call the office after you submit the camper application.


Participation Agreement I acknowledge that participation in Ray Bird Ministries’ programs involve risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: contagious disease, sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

Angel Tree/Prison Fellowship Ministries Parent/guardian of the participating child hereby grants Prison Fellowship Ministries (“PFM”) its affiliates and agents, irrevocable permission to use, record, and reproduce the image and likeness of his/her participating child in any manner and in all media now or hereafter known, for any and all purposes (including advertising and promotional use), in perpetuity throughout the world, without restriction as to alteration. Parent/guardian and participating child give this consent with no claim for payment.

We understand and are in agreement with the above statements. We certify that the above health record is accurate and complete as of this date.


Insurance Information
In the event of illness, parents are completely responsible for any necessary treatment costs incurred. In case of accident or injury, Ray Bird Ministries holds a secondary coverage status. Our insurance begins where yours ends.

SUMMER FOOD SERVICE PROGRAM

For more information and help with this section click here. (Please fill out either 2A, 2B or 2C)

PART 2A - HOUSEHOLDS NOW RECEIVING FOOD STAMPS, TANF OR FDPIR BENEFITS Complete this part and fill out only names in part 2C.

PART 2B - FOSTER CHILD

PART 2C. ALL OTHER HOUSEHOLDS: If you did not complete PART 2A or PART 2B, complete this part List ALL household members even if they have no income
Enter gross (before deductions) household income from all sources and how often it was received
First Person in Household

Second Person in Household

Third Person in Household

Fourth Person in Household

Fifth Person in Household

Sixth Person in Household

Seventh Person in Household

Eighth Person in Household

Ninth Person in Household

Tenth Person in Household

PART 3 - SIGNATURE: An adult household member must sign the statement before it can be approved.

PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the food stamp, FDPIR, TANF number is correct or that all income is reported. I understand that this information is being given for the receipt of Federal funds; that institution officials may verify the information on this application and that the deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.


Additional comments




After you submit your application you will get a postcard in the mail (in a week or so) to tell you which week your child has been signed up for, your fee amount and when it is due, and a list of things to bring.

Camp Ray Bird is participating in the Summer Food Service Program. Meals will be provided to all eligible children free of charge. Eligibility is determined by enrollment as a camper and completion of the summer camp application and income eligibility form. Children who are part of households that receive food stamps, or benefits under the FDPIR, or TANF are automatically eligible to receive free meals. Acceptance and participation requirements for the program and all activities are the same for all regardless of race, color, national origin, gender, age or disability, and there will be no discrimination in the course of the meal service. Meals will be provided at the site and times as follows:

Meal times are Breakfast-8:45, Lunch-12:45, Supper-5:30.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.