CBA Kids' Camp Registration

Kids' Camp Registration

An overnight camp designed for kids age 10-12, sponsored by the Coulee Baptist Association, held July 22-25 at Ingalls Creek Center
Camper's First Name*
Camper's Last Name*
Camper's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Date
Age*
(on the first day of camp)
Sex*

MaleFemale
Church*
T-Shirt Size*

Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Adult SmallAdult MediumAdult LargeAdult Extra Large
List yourself as parent/guardian #1 if you are completing this form as a parent/guardian of the camper.
Parent/Guardian #1 Information
Full Name*
Relationship*
Phone Number*
Email*
example@example.com
Does Parent/Guardian #1 live at the same address as the camper?*

YesNo
Parent/Guardian #2 Information
Full Name
Relationship
Phone Number
Email
example@example.com
Does Parent/Guardian #2 live at the same address as the camper?

YesNo
List the names and phone numbers of anyone else who may pick up this camper.
Camper's Medical Information
Food allergies
Other medical dietary restriction(s)
Other allergies
Medical activity restriction(s)
The camp nurse will have a limited supply of over-the-counter medications to administer as needed, possibly including acetaminophen (Tylenol), ibuprofen (Advil or Motrin), antihistamine/allergy medicine (Benadryl), topical creams (anti-itch, lotion, antibiotic), decongestants, tummy soothers, cough drops, and throat spray.
The following medications (from above list) may NOT be given:
Please send a supply of all regularly administered medications (prescription and over-the-counter). They must be turned in to the camp nurse in their original containers. Place all medicaitons into a ziploc bag labeled with the camper's name and date of birth. Include a doctor's note for any medications that require a different dosage than the listed instructions.
Do you anticipate sending this camper with any medications?*

YesNo
Select if any of the following items applies to this camper:

AsthmaFrequent headachesBedwettingHeart issuesChronic illnessRecent injuryDiabetesSeizuresDigestive issuesSleepwalkingDizziness/faintingOther
Explain any of the above issues.
Is there anything else that would helpful for us to know about this camper?
Medical insurance and doctor information is not required, but may eliminate delay in case of injury or illness that necessitates medical care away from the camp.
Camper's medical insurance company
Policy number
Camper's doctor
Doctor's phone
Payment tiers

Tier 1: $190 - this amount is the real cost of participation in the camp.
Tier 2: $160 - this rate covers the use of the rental facility.
Tier 3: $130 - this base price is made possible by assistance from the association.

Click here for more details.
Select payment tier*

Tier 1: $190Tier 2: $160Tier 3: $130
Submit your payment to the church, making a note that it's for the CBA kids' camp.
Submitting this registration form:
- gives consent to allow treatment of {campersFirst} {campersLast} by qualified medical personnel in case of injury or illness and that the person submitting this form is a parent/guardian with the authority to give such permission
- acknowledges that there are health risks associated with a camping program (injury, possibility of exposure to illness, etc.)
- indicates agreement to not hold Coulee Baptist Association liable in the event of injury, illness, or property damage
- grants Coulee Baptist Association permission to use comments, images, and/or recording of {campersFirst} {campersLast} in its online or print publications. You may opt out of this media release at check-in.
All campers are expected to attend all activities unless excused by the camp nurse or director, respect and obey those in authority, dress and behave modestly, not bring any prohibited items (pets, fireworks, weapons, anything illegal), and respect others' property. We reserve the right to send any camper home as a disciplinary measure.
Should be Empty:

Kids' Camp Registration

Camper's Medical Information

Submitting this registration form:

gives consent to allow treatment of {campersFirst} {campersLast} by qualified medical personnel in case of injury or illness and that the person submitting this form is a parent/guardian with the authority to give such permission

acknowledges that there are health risks associated with a camping program (injury, possibility of exposure to illness, etc.)

indicates agreement to not hold Coulee Baptist Association liable in the event of injury, illness, or property damage

grants Coulee Baptist Association permission to use comments, images, and/or recording of {campersFirst} {campersLast} in its online or print publications. You may opt out of this media release at check-in.