2025 Day Camper Registration Form

2025 Camp Mission Day Camper Registration

MUST BE FILLED OUT BY PARENT/LEGAL GUARDIAN
Camper Information
Which Session are you registering to be a Day Camper for?

Session OneSession Two
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Camper Tshirt Size (This is for the white craft tye-dye shirt)
Camper's Information
Address*
City*
State*
Zip*
Home Phone*

Area CodePhone Number
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Birth Date*

MonthDayYear
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Church Information
Church you attend (if any)
Church City
Church you are coming with (if any)
Email Confirmation
Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)*
Camper's Email
Other Information
First Time Camper? *

YesNo
Did you attend Camp Mission last year?*

YesNo
How did you hear about Camp Mission?
Health Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. Please bring all medication in Origional CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that campers name and the correct dosage.
Camper Medical Insurance Provider*
Medical Insurance Carrier Name*
Medical Insurance Group Number*
Medical Insurance Phone*
Family Doctor*
Family Doctor Phone Number *
Preferred Hospital/Facility for Emergency Medical Services *
Is camper free from infectious disease or conditions?*

YesNo
Are immunizations up to date?*

YesNo
Date of last tetanus shot*
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.*
Parent & Camper Acknowledgements
Do we have permission to post pictures/videos to Camp Mission Social Media accounts?*

YesNo
Does your camper have your permission to swim in the lake?*

YesNo
Does your camper have permission to participate in all camp Mission's activities, sports, & programs?*

YesNo
By Initialing below, you agree that your child will not bring any electronic devices, cell phones, ipods, ipads, tablets, etc. *
A Camp phone will be available all week for parents to call, and for campers to call home if needed.
By Initialing below, you acknowledge that you have read the camp rules (found on missiontoministry.org) with your camper and have agreed they will abide by the rules while on campus. You also agree that if your camper breaks the rules, you will come and pick them up should the directors feel the need to dismiss the camper early. *
Please click on here to read Camp Mission Rules.
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)*
By hitting submit and signing your name, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18.

In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel at Camp Mission, Mission to Ministry, and YCL Ministries & Campground. I understand that the above named camper will only be released to the names listed above, and any update may be done at registration. I certify that my child has my permission to attend camp and participate in church services, camp activities, camp sports and all that Camp mission has to offer. I authorize Camp Mission, Mission to Ministry, YCL Ministries and Campground to use my camper's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the camp.
Payment Information

Day Camper fee $100.00
Day Camper Registration $100.00 per Camper. This includes meals, crafts, daily activities for all campers.
**Note: Does not include Theme camp tshirt or snack shack/camp store items.

$50 registration is NON REFUNDABLE

Remainder of Camp Costs is due at Camp Check-In Day.

Checks can be made payable to Mission to Ministry and mailed to

110 N. N Whittenberger St.
Akron, IN 46910
Signature*

Clear
Electronic signature, please initial*
prevnext( X )
(Paypal or Credit Card)Registration Fee+Processing Fee$52.50

Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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2025 Camp Mission Day Camper Registration

Camper Information

Camper's Information

Parent or Legal Guardian Information

Church Information

Email Confirmation

Other Information

Health Information

Parent & Camper Acknowledgements

Camper Release

Payment Information