IGM Winter Camp Individual Registration Form

This form will be filled out by every attendee of the Winter Retreat. The Group Registration will be filled out by the church's Girls Ministries Coordinator, and payment will be remitted via that Group Registration.

LOCATION

Menno Haven Camp and Retreat Center, Tiskilwa, IL

Inside-lodge bathrooms!

Sledding, Climbing Wall, Open Gym

Event begins 7pm January 24th.

Are you:

a parent/guardian completing this form for your child/children?an attending leader?both completing this form for your child/children, AND an attendee at the event

Girls who attend must be accompanied by a family member or woman from their church.

Churches should have at least 2 adults for every 10 campers.

Parent Name

First NameLast Name

Leader Name

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Confirmation Email

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Church City*

Church Name*

Insurance Company Name

Policy Number/Group Number

Insurance Phone Number

Area CodePhone Number

List any allergies or dietary restrictions OF THE ATTENDING LEADER here:

How many of your students are participating?*

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

Allergies

Will this student be bringing prescription medications?

YesNo

Each student must have a completed Medication Registration Sheet (MRS) detailing all medications brought onto campus. This form will be provided to you upon completion of your registration and may be downloaded to send with your child.

Other Medical Notes

Additional Students?

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Allergies

Will this student be bringing prescription medications?

YesNo

Each student must have a completed Medication Registration Sheet (MRS) detailing all medications brought onto campus. This form will be provided to you upon completion of your registration and may be downloaded to send with your child.

Other Medical Notes

Additional Students?

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Allergies

Will this student be bringing prescription medications?

YesNo

Each student must have a completed Medication Registration Sheet (MRS) detailing all medications brought onto campus. This form will be provided to you upon completion of your registration and may be downloaded to send with your child.

Other Medical Notes

Additional Students?

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Allergies

Will this student be bringing prescription medications?

YesNo

Each student must have a completed Medication Registration Sheet (MRS) detailing all medications brought onto campus. This form will be provided to you upon completion of your registration and may be downloaded to send with your child.

Other Medical Notes

Additional Students?

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Allergies

Will this student be bringing prescription medications?

YesNo

Each student must have a completed Medication Registration Sheet (MRS) detailing all medications brought onto campus. This form will be provided to you upon completion of your registration and may be downloaded to send with your child.

Other Medical Notes

I do hereby state that I have legal custody of this/these child/children, a minor, who resides with me. While this minor is a registered camper at any Illinois Assemblies of God Retreat Activity, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said Retreat to consent to any x-ray, examination, anesthetic, medical, or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the United States, when such medical or surgical treatment is necessary. I also give my permission for my child/children to receive over-the-counter medication from the retreat nurse if necessary. I give full permission to Illinois Assemblies of God Winter Retreat staff to reproduce any photograph and/or video image of me/my student(s) for promotional usage without obligation to me/my student(s). I have read the rules and agree to abide by them and do hereby give permission for my student(s) to participate in all Winter Retreat activities.

I do hereby state that while I am a registered staff member at any Illinois Assemblies of God event, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said Event to consent to any x-ray, examination, anesthetic, medical or surgical treatment, and hospital care, to be rendered under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the United States when such medical or surgical treatment is necessary. I give full permission to Illinois District Assemblies of God to reproduce any photograph and/or video image of me for promotional usage without obligation to me. I have read the rules and agree to abide by them.

Any adult attending must pass a National Background Check. Upon completion of this form, you will be directed to a link where you can fill out your Background Check Consent Form.

Parent Signature*

Leader Signature

Please be aware, you will be directed to a Thank You Page and receive a confirmation email if your submission is successful. Please check your spam filter if you do not receive the email. If you do not receive one or both of these, then your submission was not successful. Feel free to contact our office if you have any question as to whether or not your submission was received. Thank you!

If you have any questions please feel free to contact Cheri Hayes at cherikhayes@gmail.com.

Thank you!

Girls Ministries Winter Camp

Student #1 Info

Student #2 Info

Student #3 Info

Student #4 Info

Student #5 Info