Ikthoos Senior Camp 2025 Registration Form

Ikthoos Senior Camp 2025 Registration Form
This form registers your camper for Ikthoos Senior Camp:

Thursday, July 10, 2:00 pm - Monday July 14, 11:30 am (13yrs. & up or finished the 6th grade )

Cost: Early Bird Registration $210, Regular Registration: $235

Cost Includes meals, housing and t-shirt.

No lunch will be served for campers on Thursday.

Please note! In order to receive the early bird discount, full payment must be received (or postmarked) by June 2. Payment may be mailed to PO Box 125, Starkville, MS 39760. There is no online payment option this year.
Registration Deadline: Early Bird - June 2, Regular Registration - June 30
Camper Last Name*
Camper First Name*
Gender*

MaleFemale
Age*
Birth Date*

MonthDayYear
Grade in 2024-2025*
T-shirt Size*
Roommate Request (Full Name) Please read statement below.
If a roommate is not requested, one of similar age will be assigned. Please check in advance with proposed roommate to ensure that both roommates request one another to be certain that request will be honored. If plans change, and roommate request needs to be adjusted, please reach out to ikthoosreg@gmail.com. Changes to roommate requests are based on availability and cannot be guaranteed.
Is camper attending with a group?*

YesNo
Group name
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Parent/Guardian E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ikthoos Health Record (Camper)

(Please Complete: Information to be shared with Ikthoos staff as needed)
Emergency Contact Information*
Camper's Medical History
Allergies*

YesNo
Please list Allergy, any Medication, Dosage, and Frequency.*
Asthma*

YesNo
Medication, Dosage, and Frequency: *
IF YES, SUBMIT ACTION PLAN FROM DOCTOR to PO Box 125, Starkville, MS 39760 when submitting registration fee.
Attention deficit (ADD, ADHD)*

YesNo
Medication, Dosage, and Frequency: *
Bone or joint problems/Physical handicap*

YesNo
List: *
Convulsions/Seizures*

YesNo
Medication, Dosage, and Frequency: *
IF YES, SUBMIT ACTION PLAN FROM DOCTOR to PO Box 125, Starkville, MS 39760 when submitting registration fee.
Diabetes*

YesNo
Medication, Dosage, and Frequency: *
IF YES, SUBMIT ACTION PLAN FROM DOCTOR to PO Box 125, Starkville, MS 39760 when submitting registration fee.
Earaches (Frequent? Tubes?)*

YesNo
LIst*
List symptoms and medications needed
Emotional / Psychological disorder*

YesNo
Please list Disorder, any Medication, Dosage, and Frequency*
List symptoms and medications needed
Headaches (Frequent or takes medication)*

YesNo
List*
List symptoms and medications needed
Heart Problems / Blood Disorders / Hypertension*

YesNo
LIst*
List symptoms and medications needed
Nose bleeds*

YesNo
List*
List symptoms and medications needed
Sinus Problems*

YesNo
List*
List symptoms and medications needed
Speech / Hearing / Vision Problems*

YesNo
List*
List symptoms and medications needed
Stomach or digestive problems*

YesNo
List*
List symptoms and medications needed
Are there any other health concerns that Ikthoos Camp should be aware of?
Is the camper taking daily medication?*

YesNo
Please list Medication, Dosage, Frequency, Time to be given, and Route.*
List name of medication & directions for use, including dosage, time to be given, and route
If medications are to be given at camp, please send in original container clearly labeled from the pharmacy.
Do you give permission for your child to administer his/her own medication without supervision from a staff member?*

YesNo
If your child has pain or fever, do you give permission for us to administer acetaminophen (Tylenol)?*

YesNo
If your child has pain or fever, do you give us permission to administer ibuprofen (Motrin/Advil)?*

YesNo
If your child has an allergic reaction, do you give permission for us to administer Benadryl?*

YesNo
If your child has a cut or scrape, do you give permission for us to apply first aid ointment?*

YesNo
If your child has need of sunscreen, do you give permission to provide sunscreen for their use?*

YesNo
By signing this registration form, I give my permission for my child to receive first aid care as needed. I give my consent for pertinent medical information to be shared between the medical provider and the Ikthoos staff/personnel directly involved with my child at Ikthoos camp.

By signing this registration form you acknowlege that your camper's photograph my be used in print and online media.
Parent/Guardian Signature:*

Clear
Draw signature with mouse
Payments may be mailed to

IKTHOOS Camp
PO BOX 125
Starkville, MS 39760

Checks may be made payable to Emmanuel Baptist Church - Ikthoos Account.

There is no online payment option this year.

In order to receive Early Bird pricing, full payment must be received/postmarked by June 2 (or postmarked by June 2).

If you have questions, please call 1-662-324-1000.
Date*

MonthDayYear
Date
Should be Empty:

Ikthoos Senior Camp 2025 Registration Form

Registration Deadline: Early Bird - June 2, Regular Registration - June 30

Ikthoos Health Record (Camper)

Camper's Medical History