Clone of 2025 Family Camp- Full-time Camper Registration

Date

Camper Information

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Home Church

Will you be registering anyone under the age of 18?

Parent/Guardian Information - if under 18

Is Parent/Guardian Information the same as listed above?

Name

First NameLast Name

Name

First NameLast Name

Parent/Guardian Phone Number

Format: (000) 000-0000.

Including yourself, how many campers will you be registering today?:

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

I hereby agree to abide by Camp Rules as defined by camp leaders:

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Do any of the campers have any allergies, chronic illness, or medical conditions? If yes, please describe:

Informed Consent and Acknowledgement

I understand that the insurance all campers are required to pay for is not a health/hospital insurance, but is strictly a liability insurance to protect the camp association.

Whereas, the Board of Directors of the Cowden Camp Association (CCA) makes the Cowden Camp facilities available for campers: and in consideration for the privilege of using the Cowden Camp facilities through its offices, agents and employees, we do hereby remise, release and forever discharge the CCA and all its actions, claims and demands for, upon, or by reason of injury, damage, loss or death which may occur from the use of Cowden Camp.

In case of medical emergency, I understand an effort will be made to contact the undersigned parent or guardian. In the event I cannot be reached, I hereby give the permissions to the physician and/or hospital selected by the camp president to give the treatment for the camper or campers named herein in the manner and to the extent necessary in the opinion of said physician and/or hospital to care for the camper or campers.

By checking the box below, I acknowledge that I have read the above informed consent and acknowledgment

Housing (Check all that Apply) * Contact the registrar for daily rates

Please indicate the number of teens who will be staying in the Boy/Girls Dorm:

***Please note that you will still need to reserve a bed with the Registrar. Completion of this form DOES NOT secure a space in one of our dormitories. To reserve a room in either the Boy/Girls dorm or the Family dorm, please contact Donna Hodge at 217.825.3420 OR via email at donnahodge103@gmail.com.

Housing Sub-total

Adult Meals (13 +) are $75/camper

Child Meals (4-12yrs) are $25/camper

Child Meals (0-3yrs) are free

Please explain if the number you are registering differs from the number in your meal plan

Meals Sub-total

Available Discounts:

Discount

SUB-TOTAL

Insurance - $5/camper (Required for every camper)

Insurance Sub-total

If you would like to assist other campers in need enter an amount here:

GRAND TOTAL DUE:

TOTAL DUE:

I will be paying my registration by:

If you are writing a check, please make your check out to Cowden Camp Association in the amount of ${grandTotal} and send it to:

Melody Smith
801 S. Saint John St.
Bethany, IL 61914

Otherwise, you may pay for your registration via the credit card option below.

NOTE: You do NOT have to have a PayPal account to use the credit card feature. To pay via credit/debit card select the last option (black button with the credit card icon)

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Pay by Credit/Debit Card

USDDescription

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2026 FULL-TIME CAMPER REGISTRATION

CAMP DATES ARE JULY 10 - 18

Personal Information

Camper Registration

EXPENSES

Housing

Meals

Discounts

Insurance

PAYMENT

PLEASE SELECT PAYMENT METHOD OR CLICK SUBMIT AT THE BOTTOM OF THE FORM IF PAYING BY CASH/CHECK.

Pay by Credit/Debit Card