Registration Form


Name: ___________________________________________ Event Attending: _________________________

Address: _________________________________________ Date of Event: ____________________________

City/St./Zip: ________________________________________________ Bunk Preference: Upper _____ Lower _____

Male: _____ Female: _____ Age: _____ Cabin Partner: _________________________________________________

Grade this Fall: _____ Immersed Believer: Yes _____ No _____

Parent: ____________________________________________ Email: ___________________________________

Day Phone: _______________ Night: ________________ Cell: ____________________  

Camper's Home Church: __________________________________________


 



 


 
 

 
 
 
 

THIS FORM MUST BE FILLED OUT AND SIGNED BY THE PARENT OR GUARDIAN

A. I certify that (camper's name) ___________________________________________ is in good physical health and carries no illness that would endanger the health of other campers or staff.

B. Camper age: ________ Birthday: ___________________ Date of last tetanus or booster: ___________________
   
 C. Emergency phone numbers: Home ________________ Business ________________ Other ________________

D. List any known allergies (plant, animal, bee, medicine, etc.) __________________________________________

E. List any medications the camper will bring with him/her to camp __________________________________________
(REMEMBER THESE MEDICATIONS WILL NEED TO BE GIVEN TO THE CAMP FIRST AID SUPERVISOR)

F. I acknowledge that accident insurance only is provided by Southern Illinois Christian Service Camp, which will go into effect after our family insurance has been charged or if I have no insurance. If my child becomes ill and is subsequently hospitalized, our family insurance will be responsible or me personally.

G. I hereby release the management, staff, volunteer workers, or officers of Southern Illinois Christian Service Camp of any responsibility for accidents unless guilty of negligence.

H. In case of emergency, I hereby give permission to the physician selected by the camp management to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child named above on this form. I understand, however, that every effort will be made to contact me in case of any such emergency before any such treatment is administered.

I. I give permission for camp photos or videos that include my child to be used for camp promotion.
Signature of Parent or guardian _________________________________________________ Date: _________________

 (Office Use: Cabin __________ Bunk __________ Group __________)

Office Use
 Cabin:_____ Bunk:_____Group:_____

Office Use
 Here:_____Not Here:_____

Sponsoring Church Use
Church:___________________________ will pay $_________ of Camper's fee. Signed:________________________

Office Use Only

Camper Paid in Full:_________                                                            Church Paid in Full:__________

Camper Amt. Due: $_________                                                            Church Amt. Due: $__________

Amt. Paid: $_______________     Date: ___________                            Amt: Paid: $_________ Date: _____________

Balance: $_________________                                                            Balance: $__________________