CrossView Christian Camp and Retreat Center
2024 Summer Camp Registration Form/Medical and Liability Release
Leadership Camper Name
*
First Name
Last Name
Parent/ Guardian signature (if participant is a minor)
*
Relationship to Minor (put n/a is participant is not a minor)
*
Today's Date
*
-
Month
-
Day
Year
Date
Signed (Parent/Guardian of Minor Participant) :
*
Today's Date
*
-
Month
-
Day
Year
Date
2024 Leadership Camp Registration Form
Leadership Camper's Legal Name
*
First Name
Last Name
Nickname
Gender
*
Male
Female
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2015
2014
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2012
2011
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1928
1927
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1925
1924
1923
1922
1921
1920
Year
Age
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T-shirt Size
*
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
Adult XXL
Participant Height/ Weight
*
Date of Last Tetanus
*
-
Month
-
Day
Year
Date
Chronic Conditions:
*
Recent Surgery:
*
Medications & Dosages currently taking:
*
Please list ALL current medications and dosages
Bladder/ Bowel Problems?
*
yes
no
If yes, please explain:
Please list any and all Learning Disabilities, Behavioral Problems, and/or Mental Health Diagnoses
*
i.e. Dyslexia, ADD, ADHD, Depression, Runaway, Bipolar, Anxiety, Autism, OCD, Eating Disorder, etc.
Is this participant in foster care?
*
yes
no
If yes, what is the level of his/her care
Has the participant ever been in residential treatment?
*
yes
no
If yes, when/ why?
Other helpful information we should know about this participant:
*
Please list all allergies (drug/ food/ bee stings/ etc)
*
Health Insurance Company
*
Policy #
*
This participant has all the vaccinations required to attend a Texas Public School.
*
yes
no
Hospital Preference
*
Physician Name:
*
First Name
Last Name
Physician Phone #:
*
Please enter a valid phone number.
Parent/Guardian Information
Parent/ Guardian Name
*
First Name
Last Name
Cell Number
*
E-mail
*
example@example.com
Emergency Information
Emergency Contact's Name
*
First Name
Last Name
Relationship
*
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Other
Phone Number
*
Alt. Phone Number
*
An opportunity for water baptism will be presented during the participant's week of Camp. Every person baptized at CrossView receives a signed “baptism letter” with a color picture of their baptism. In the event your participant expresses an interest, do you give your consent for him/her to be baptized (if participant is a minor)?
*
yes
no
What is this participant's family situation:
*
Please Select
2 parent
single parent
step parent
grandparent
foster care
other
Are any adults in this household unemployed?
*
yes
no
Has this participant been retained in a grade at least once?
*
yes
no
Has this participant ever been in foster care?
*
yes
no
Is this participant a "sibling" of foster child(ren)?
*
yes
no
What is this participant's race?
*
Caucasian
Hispanic
African-American
Asian
American Indian
Other
Has either of this participant's parents ever been in the Criminal Justice System (even if a non-custodial parent)?
*
yes
no
Has this participant ever been enrolled in an AEP (alternative education program like PAC or Project Intercept)?
*
yes
no
I certify that the above information is true and correct to the best of my knowledge.
*
Today's Date
*
-
Month
-
Day
Year
Date
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