Summer Workcamp Registration
July 22-26, 2026 | Rockford, Illinois | Cost: Free | Register by June 30, 2026
Participant's Name
*
First Name
Last Name
Participant's Address
*
Street Address
Street Address 2
City
State / Province
Postal / Zip Code
Participant’s Phone Number (If your child does not have a phone, please provide your own number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant’s Email
*
example@example.com
Participant’s Birthdate
*
-
Month
-
Day
Year
Date
Parent's Email (Important updates and notices will be sent to this address):
*
example@example.com
Do you need scholarship for the workcamp?
Yes
No
Sleeping Area
*
Participant would like to stay at the church during Workcamp.
Participant would like to stay at home and come back to the church each morning during Workcamp.
Photo Release
*
I give permission for photos of my child to be taken and used for church-related publications and social media.
I do not give permission for photos of my child to be taken and used.
T- Shirts Size (Adult size)
S
M
L
XL
2XL
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Emergency Contact #1
Name
*
First Name
Last Name
Primary phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
Name
*
First Name
Last Name
Primary phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Family physician
*
First Name
Last Name
Family physician phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance carrier:
*
Insurance phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance ID or group number:
*
Policyholder:
*
First Name
Last Name
Allergies:
*
List any limitations on activity or special diet/health concerns:
Date of last tetanus immunization or booster:
*
-
Month
-
Day
Year
Date
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Medication Record
Participant name
*
First Name
Last Name
Will a parent send medications?
*
Yes
No
N/A
Parent 1 Name
*
First Name
Last Name
Parent 2 Name
First Name
Last Name
Parent 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Medication 1
Medication name and strength
*
Dosage and frequency
*
Amount of medication sent
*
Medication 2
Medication name and strength
Dosage and frequency
Amount of medication sent
Medication 3
Medication name and strength
Dosage and frequency
Amount of medication sent
List any additional medications (name, strength, dosage, frequency, amount sent):
May child alter medication schedule?
Yes
No
If yes, how?
Comments/concerns:
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Parental Agreement
We, the parents/legal guardian of the child named above, do hereby consent to our said child participating Workcamp 2026 in connection with Christ United Methodist Church on the dates indicated. We assume all risks and hazards incidental to such participation, and we do hereby release, waive, absolve, indemnify, and agree to hold harmless Christ United Methodist Church, their officers, agents, and any leaders, coaches, helpers, assistants, and person supervising or assisting or in any way connected with such activity for any claim arising out of or injury to our child as a result of such activity. In the event of injury or sudden illness to our child, we further specifically authorize the staff or adult leaders from Christ United Methodist Church to consent on our behalf to any emergency medical treatment recommended by a duly licensed physician and for that limited purpose and extent, we do hereby appoint such person as our attorney-in-fact to so consent on our behalf. I (we) understand that it is my (our) sole responsibility to check with my physician regarding any physical or psychological problems which may limit our child’s participation in this program. Further, it is my responsibility to have valid and sufficient medical and accident insurance for the duration of this program. I know that Christ United Methodist Church is not responsible to provide this coverage. If my son/daughter is in possession of or is reasonably suspected of using or taking tobacco, alcohol, or non-prescription drugs, he/she may, at the discretion of the Christ United Methodist Church staff or volunteers, be sent home at my expense. I also understand that both moving and still photos of my child may be taken and used for promotional purposes of Christ United Methodist Church.
*
I agree to the above statement
Camper Participant Agreement
I, the participant, understand that although Christ United Methodist Church has taken care to provide proper equipment, suitable facilities, and trained staff, it is impossible to guarantee absolute safety. I understand that I must assume responsibility for my own safety. This means that I agree to follow any instructions and directions given me by the staff and leadership and will seek to act carefully and with good judgment. I also agree to participate fully in all programming. Furthermore, I agree that the staff or volunteers of Christ United Methodist Church may search any of my possessions, and I consent to that search. Further, I agree not to carry, possess, or use any alcohol, tobacco, or non-prescription drugs of any kind at this retreat. I understand that a violation of this contract of camp rules will result in an immediate dismissal from the camp at my expense.
*
I agree to the above statement
Do you have any questions or concerns?
Participant Signature
*
First Name
Last Name
Parent Signature
*
First Name
Last Name
Submit
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