2026 FBC Camp Jim Camper Registration

2026 Camp Jim Registration

Hosted by First Baptist Church of Rosemount
Camper Information
Camper Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Last School Grade Completed
Requests a Cabin With:
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Cell Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Please list any Dietary Restrictions (food allergies, food restrictions due to religious beliefs, etc.) We will not be able to accommodate any food restrictions that are not noted on this form.
Does your camper have any medications they will be bringing to Camp?
***Please Note*** Any medications must be turned in to First Baptist Church representatives at check in and MUST BE in original packaging. Medication will ONLY be dispensed according to label directions.
I give permission for my child to be given (Please select ALL that apply):
Hold Harmless Agreement

By submitting this form, permission is granted for the above-named individual to participate in the camping program of First Baptist Church of Rosemount. It is specifically understood and agreed that the above activity is at the undersigned's personal risk. First Baptist Church and its agents/employees and the leader in charge will be held harmless and will not be liable for any accident resulting in a personal injury, permanent or otherwise, or for any death resulting from such an accident. It is further understood and agreed that the leader and/or his agent may use their own judgment as to whether or not the individual should be taken to a medical facility for examination, x-rays, and/or hospitalization. The undersigned also agrees to assume all financial responsibility for any such medical aid thus rendered. The camper is the party responsible for such damage. This hold harmless agreement shall be filed in the office of Pastor Clear and shall remain in force throughout the duration of this camping activity.
Medical Release and Authorization As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to First Baptist Church and its affiliates including Directors, Counselors, and other Representatives to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered camp Session. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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
Cost:

Early registration opens at the beginning of June. The early registration cost is $150 per camper for payments received by July 19. After July 19, the registration cost will increase to $175 per camper. All payments must be submitted by cash or check prior to campers departing on July 27.
Should be Empty:

2026 Camp Jim Registration

Cost: