Camp Christian, Inc · 2024 Jr/Sr High Fall Retreat

Contact Information

Camper Name *

First Name

Last Name

Gender *

Male

Female

Camper goes by:

Please let us know if camper has a nickname (ie: Elijah goes by Eli)

Date of Birth *

Please format MM/DD/YYYY

Grade *

Camper Email (optional)

Verify Email

Mailing Address *

City *

State *

Zip Code *

Home Phone

only if have home phone

Church Attending

Church City

Has Camper been baptized by immersion *

*Parents will be contacted for permission if camper expresses desire to be baptized*

Yes

No

Is this camper's first time at Camp Christian? *

Yes

No

Coming as a friend of *

If camper is coming with a friend, please list friend's name above.

Parent/Guardian Information

Email belongs to: *

Parent/Guardian Email *

Verify Email *

FEMALE'S Information

First Name

Last Name

Relationship

If other, please specify relationship *

Female's Contact Number

Contact number is

Cell

home

work

MALE'S Information

First Name

Last Name

Relationship

If other, please specify relationship *

Male's Contact Number

Contact number is

Cell

home

work

Additional alternate emergency contact person

First Name

Last Name

Relationship to Camper

Emergency Contact Number

Contact number is

Cell

home

work

If parent/guardian contact is necessary, please first contact: *

Please list name and contact number

Liability Release: I release Camp Christian, including it's directors, employees and agents from my child's physical injury, including death, or illness while at camp, including Camp Christian sponsored travel to and from camp. I will assume the risks associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.

Off Camp Release: My child has permission to be transported for medical care or to participate in programs conducted off the Camp Christian grounds. It is understood that off ground programs are supervised by qualified camp faculty.

Publicity Release: I give permission to Camp Christian staff or the assigns to use photos, videos & audio recordings in promotional materials and/or post them on the camp's website or social media.

General: I recognize that this is a Christian camp, the Bible will be studied, and camper conduct and dress is expected to be in line with Christian values. I understand that my camper is expected to attend all sessions and activities. I also understand that if my child refuses to conduct himself/herself in this manner, I may be required to pick up my camper.

Release Agreements - Please type your name below. *

By typing my name above, I acknowledge that I have read and agree to the above agreements.

Medical Insurance Company *

Policy Number *

Date of last tetanus shot:

(mm/dd/yyyy)

Camper has the following (any): *

ADD/ADHD

Asthma

Diabetes

Frequent Ear Infections

Heart Condition

Seizures

Fainting

Sleep Walking

None of the Above

Other Health Conditions of which we should be aware?

ALLERGIES: Please lis any food, medication and insect allergies. Describe reaction & management of reaction

Allergy

Reaction & Management *

Allergy 2

Reaction & Management 2 *

Allergy 3

Reaction & Management 3 *

MEDICATION POLICY

MEDICATIONS: Please list all medications (Prescription/Over-the-counter/Vitamins/Herbs) below. ALL medication must be in the ORIGINAL CONTAINER and will be left with and dispensed by the Health Supervisor. Medicines must be kept in the original packaging/bottle that identifies the prescribing physician, name of medicine, dosage & frequency. Do not bring prescription medicine in a generic M-S container, plastic bags, or any container that is not from the pharmacy. NO medicines, vitamins, herbs, melatonin, etc are permitted to be kept in the dorms with your child with the exception of Inhalers and Epi Pens. The Health Supervisor must be advised of any Inhalers and Epi Pens being kept by campers.

PLEASE ADVISE: (NEW FOR 2023) If your child will be taking any over the counter: allergy medicine, supplements, vitamins, herbs, (INCLUDING MELATONIN) etc...while at camp, you MUST bring a doctor's note. Please understand, we can not give these any other way.

We understand that medications may change and will update this at check-in.

Is Camper currently taking any medication (Rx, OTC, Vitamins, Herbs) *

Yes

No

Name of Medication

Dosage and Time(s) of Day Medication Taken *

Name of Medication 2

Dosage and Time(s) of Day Medication 2 Taken *

Name of Medication 3

Dosage and Time(s) of Day Medication 3 Taken *

Name of Medication 4

Dosage and Time(s) of Day Medication 4 Taken *

Name of Medication 5

Dosage and Time(s) of Day Medication 5 Taken *

Name of Medication 6

Dosage and Time(s) of Day Medication 6 Taken *

Health Center Medications

These medications are stocked at Camp Christian. Please indicate your permission to administer these over-the-counter medications, or if you wish to be notified first. (Some meds are listed as common brand names, though generic may be substituted.)

Acetaminophen *

Tums *

Ibuprofen *

Pepto-Bismol *

Benadryl *

Neosporin *

Cold Medicine *

Hydrocortisone Cream *

Cough Syrup *

Calamine Lotion *

Cough Drops *

I certify that my child is in good physical condition and is able to participate in all camp activities EXCEPT:

To the best of my knowledge, my child is physically and emotionally able to take part in the camp program. In the event of a medical emergency, I give my permission to those in charge at Camp Christian to seek necessary medical attention from qualified personnel (Nurse, Physician, EMT or other Medical Professionals) to do what is necessary for the health and well-being of my child. I give my permission for emergency medical care to be administered if necessary, understanding that every effort will be made to contact me.

Parent/Guardian Signature *

By typing my name above, I certify that I have read and agree to the above statements.

Any other comments or things of which we should be aware?

REGISTRATION FEES

A nonrefundable deposit of $20 is due with registration. Balance payable before or at check-in.

$65 - Paid in Full

$30 - $30 paid by church

$20 - Deposit