registration form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father:

Phone:

Mother:

Phone:

Age

Date of Birth:

Grade This Fall:

Home Church:

Gender:

MaleFemale

Shirt Size

Parents Email Address:

Program:

Allergies:

Physical, Medical or Emotional disabilities

Other important medical history

Camper taking medication

YesNo

Please list medications

Date of last tetanus booster

Insurance Company

Policy Number

Over the counter medicines I do not wish to be administered to my child

I the parent/guardian of the above named camper give my permission for the personnel at Southern Illinois Christian Service Camp to care for minor illnesses/injuries using over the counter medication and basic first aid procedures.

In the case of emergency, SICSC will make every effoert to contact those listed on this form. In the event that SICSC is unable to contact myself I give permission to the camp to secure treatment for my child as named on this form.

I understand that the completion of this medical form with my signature grants the camper participation in a SICSC program. I understand that the camper is to abide by all camp rules, policies and the code of ethics. I release SICSC staff, faculty, officers and management from liability.

For some programs we take campers off the camp property. Examples of this would be to the lake for swimming, bowling, skating, to various parks, service projects and various events. By signing this form I give my permission for my child to travel to the off site activites.

Signature

Clear

Date:

Photo Release

I hereby give permission to Southern Illinois Christian Service Camp to use photographs of my child taken bt the official or volunteer staff to be used for related camp activities, programs or promotion including the web site of SICSC. I also recognize the these photographs are property of SICSC.

Code of Ethics

1. Campers failing to respond to the authority of the camp staff will be sent home.

2. Campers who fail to abide with the camp schedule (exceptions: sickness, etc.) will be sent home

3. Campers caught stealing or pilfering through others belongings will be sent home.

4. Unacceptable behavior will not be tolerated. Any act deemed unacceptable by SICSC staff, Camp Dean or faculty will result in dsimissal.

5. Campers who destroy camp proprerty will be responsible for the cost of repair or replacement.

6. Any camper caught with alcohol, tobacco, vape, drugs or weapons will be dismissed.

7. Campers are expected to treat others in a Christian manner.

8. Report all illness or injury to the camp nurse immediately.

9. Modest attire will be worn at all times.

10. I will not bring anything on the do not bring list.

I have read and understand the guidelines listed above and agree to follow them.

Camper Signature:

Clear

Date:

Parent Signature:

Clear

Date:

Church Contribution:

Canteen Amount:

Donation:

Balance Due

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Paypal Total

USDDescription

Payment Methods

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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SICSC Registration Form 2023