Middle School 2020 Camp Registration Form

Student's Name *

First Name Last Name

Date of Birth *

Month Day Year

Student's Shirt Size *

Grade Completed in 2020-2021 School Year *

Which campus do you attend? *

My student is a:

Non-swimmer Fair swimmer Good swimmer

Gender *

Female Male

Student's name you would like your child to room with

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail *

Parent's/Legal Guardian's Name *

First Name Last Name

Cell Phone Number *

Area Code Phone Number

Alternate Phone Number

Area Code Phone Number

Student's Height *

Student's Weight *

Allergies

My student can have any of the following OTC medications in accordance with standard label directions. (Check all that apply.)

NONE Tylenol Ibuprofen Antihistimine Decongestant Cough Medicine Anti-nausea Anti-diarrhea

Emergency Contact #1 *

First Name Last Name

Phone Number *

Area Code Phone Number

Relationship to child *

Emergency Contact #2

First Name Last Name

Phone Number

Area Code Phone Number

Relationship to child

Photocopy of the front and back of the insurance card MUST be provided by uploading the file in the space below.

Please indicate "N/A" in the required fields below if the camper has no insurance.

Photocopy of Insurance Card

Medical Insurance

Insured's Name

Policy #

Phone(Insurance Co.)

Please list ALL medications taken routinely. Bring medications in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

NAME OF MEDICATION #1

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

NAME OF MEDICATION #2

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

NAME OF MEDICATION #3

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

NAME OF MEDICATION #4

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

PHOTOGRAPH RELEASE

I hereby give Crossroads permission to use photographs/video/sound of the child named in this registration form for publicity, promotion, news releases, videos, and web use of Crossroads. This might also apply to the written composition or visual art of the person if it is published. This would only be for the church use and marketing promotion.

Parent/Guardian Signature for Photography Release

Payment *

Early Bird Registration Until February 22 (MUST BE PAID IN FULL) $ 375.00

Deposit (Locks in regular price $400) $ 150.00

Cash/Check Payment "Contact Church for Payment Processing" Free

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

By checking this box you are authorizing Crossroads Church to charge your credit card. *

Credit Card Authorization

Which Parent/Camper Meeting will you attend? *

PARENT/GUARDIAN PERMISSION

I hereby give my permission for the child named in this registration form to take part in all Crossroads activities. I hereby give my permission for the designated/approved church representative or sponsor to secure any needed medical treatment for the aboved named child. I release Crossroads Church from liability for accident or injuries on these trips or from these activities.

I further understand and agree that, in the event that the above named child be involved in any non-Christian or dangerous behaviors/activities, I will pay his or her expenses to be sent home immediately at the discretion of the approved sponsors and/or church representatives.

I have supplied, understood, and agree to all the information contained on this document.

Parent/Guardian Signature for permission to participate in all Crossroads activities, and releases Crossroads Church from liability for accidents or injuries on this trip *

Date signed *

By clicking submit you are agreeing that ALL payments are non-refundable.

Middle School 2021 Camp Registration Form

HEALTH INFORMATION

MEDICATIONS BEING TAKEN