Registration Form

CORE 2:15

2025 Camper Registration Form
Camper Name:

First NameLast Name
Camp
Grade entering in Fall
T-Shirt Size
School
Church
Emergency Contact Information

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.

ONLY EMERGENCY CONTACTS ARE ALLOWED TO PICK UP CAMPERS.
Parent/Guardian

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Contact

First NameLast Name
Phone Number

Area CodePhone Number
I authorize CORE 2:15 use of any media taken of my child at camp for promotional use.

I doPlease don’t
Assumption of Risk
The parent/guardian assumes all risk and danger incidental to the activity of camping in a rustic outdoor environment including specifically (but not exclusively), the danger of being injured by insects or animals, of being injured by participating in recreational activities or of being injured as a result of inclement weather conditions, and agrees that CORE 2:15 and its’ owners, agents, and employees are not liable for injuries or property damages resulting from such causes.
Signature

Clear

Camper Health Form

Page One
Camper Name

First NameLast Name
Date of Birth
MM/DD/YYYY
Male or Female

MaleFemale
Provide information regarding your child’s allergies, dietary or physical restrictions and medications in the boxes provided below.
Allergies
i.e stings, hay fever etc. If none type N/A
Dietary Restrictions
i.e food allergies or intolerance of any kind. If none type N/A
Physical Restrictions
i.e healing bones, asthma or other that would effect their ability to participate in activities. If none type N/A
Medications
Please list all medications, when they’re taken, how they’re taken and dosage. If none type N/A

Camper Health Form

Page Two
Primary care doctor
Phone Number

Area CodePhone Number
This camper is covered by family medical/hospital insurance?

YesNo
Medical insurance information
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Signature

Clear

Thanks!
Please share any questions or concerns:
You can call anytime 574-345-1858
You’ll receive a confirmation email from within 24-72 hours of submission.

Additionally a parent orientation packet will be emailed out the week before arrival.

We look forward to serving you and your child very soon!
Registration fee

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USDGrade 3-4 $60, Grades 5-6 $75, Survival $25, Art $60

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CORE 2:15