Registration Health history A PARENT OR GUARDIAN MUST SIGN THE General Information
FOLLOWING PERMIT:
Name______________________________ Week___________________________________________ Registration: Monday at 11 AM (Lunch included)
To the best of my knowledge this Health
Age_____DOB___/___/___ Grade Fall 2019_________ Name___________________________________________ Departure: Saturday 10 AM
History is accurate. I am in favor of and
M__ F__ Age_________DOB___/___/___Grade Fall 2019______ grant permission for the child on this form to What to Bring:
Address_________________________________________
attend camp and participate in all
__M __F *Bible, pen, notebook, pillow, sleeping bag or bedding,
activities unless otherwise specified. As insect repellent, all necessary toiletry items, towels,
City_______________________State_________________ Address___________________________________ parent or legal guardian, I accept the swim towels, tennis shoes, shoes and clothes that can
Email____________________________________________ City_______________________________ST_____Zip________
conditions stated, including the release of get wet, jacket, swimsuit, spending money
the Slippery Rock Baptist Camp from liability (approximately $25-$35 for snacks and souvenirs).
Home Phone____________________________________ Emergency #_____________________________ in the case of injury or illness. What not to bring:
Church Name___________________________________ Father____________________________________
I hereby give permission to the hospital and Any electronic devices (ipods, laptops, games, radios,
Church Home#__________________Cell#_____________________ the medical personnel selected by the etc.), magazines, illegal drugs, any type of firearm or
City/State__________________________ZIP___________ weapon of any kind, cigarettes, tobacco, alcohol,
Work#_____________________________________________
director of SRBC, or his designate, to order firecrackers, or non-prescription drugs.
Pastor___________________Phone___________________ treatment for my child. In the event I
Mother____________________________________________ cannot be reached by the Director, or his Dress Code:
Father__________________Work/Cell________________
Home#__________________Cell#____________________ designate, to render whatever emergency We ask that bathing suits be one piece and modest
Mother_________________Work/Cell________________ treatment may be judged necessary, to for girls and boxer type shorts for boys (there will be
Work#____________________________________________ separate swim times for boys and girls). Please no
*Cabin Mate Request____________________________ hospitalize, and secure proper treatment
spaghetti strap tank tops or shorts shorter than two
Insurance Carrier_________________________________ for the child named on this application. I inches above the knee.
* Limit two cabin mate requests. We’re sorry, but we
can’t make any guarantees. Policy#_________________Carrier
agree to the release of any records
necessary for treatment, referral, billing or Because of our desire to keep others from stumbling,
Phone_________________
Please Check All that Apply we ask that our campers and staff alike dress modestly.
insurance purposes.
Policy Holder
___Family Camp (July 1-6) Please see info Extra Camp Costs:
Name______________________________________________ Print Name_______________________________
___Primary Day Camp (July 1-5)-1st-3rd ($55) Snack shop, Camp store, Café, Mocha Motion,
Name(s) of an individual who may make decisions on
your behalf in an emergency, if parent or guardian is
Signature_________________________________ Paintball ($10 to play, $4/100 balls) and Crafts.
__Senior High Camp (July 8-13)-9th-12th ($230)
unavailable. Health and Safety:
Relationship______________________________
__Junior Camp (July 15-20)-4th-6th ($230)
Name_______________________________________________ We are committed to providing a safe and enjoyable
__Junior High Camp (July 22-27 -7 -9 ($230)
) th th Date ____/____/____ camping experience for all of your campers. A fulltime
Relationship_________________________________________
registered nurse is available 24hrs and a certified
*Please include entire registration fee ($55) for I give permission for any pictures and lifeguard is present during swimming activities. Our
Home#______________________Cell#__________________
overnight camps. Registration fee is deducted from personal quotes of the child on this form to health center is supplied with OTC medications. Please
camp price when balance is due. No refund on Work#______________________________________________ be used for promoting the camping do not send any OTC medications with your campers.
registration fee. Prescription medications may be sent with instructions
Check if camper has any of the following:
program through brochures, newsletters,
for the nurse who will administer them at the regular
Attend a second week of camp for $100. website, and other publicity tools at SRBC. dosage time.
No discounts for day camps. ___Headaches ___ADD ___Diabetes
Print Name:_______________________________
___$20 off early registration (postmark by May 1, 2018) ___Nightmares ___Bee Sting Allergy ___Asthma
___$10 off early registration (postmark by June 1 ,2018) ___Ear Problems ___Seizures ___Heart Problems
Signature_________________________________
___No early registration ___Sleep Walking ____Depression/Anxiety Relationship_______________Date___/___/___
Office use only******************************************* Medication allergies ___Y___N
Photo Permission ______
List__________________________________________________
2019 Schedule Family Week
_____________________________________________________
July 1 -6th
st
April 26-27 Spring Youth Retreat List any dietary
Camp for all Ages
restrictions___________________________________________
May 3-4 Men’s Retreat _____________________________________________________
**Fireworks July 3rd**
__
May 10-11 Ladies’ Retreat
Cost: Tent (no electric) $325/family
Any food allergies ___Y___N
June 3-7 Work Week #1 RV (with hook ups) $350/site
Allergic reaction is: ___Mild ___Moderate
June 10-14 Work Week #2 Cabin (s) Price below:
___Severe
July 1-6 Family Camp Adults $150/week List:_________________________________________________
July 1-5 Primary Day Camp Ages 5-17 $90 List medications currently being taken. All medications,
except inhalers and EpiPen’s, are to be given to the
July 3 Fourth of July Celebration Ages 4 &under Free nurse at registration. I (as the parent/guardian)
authorize the camp nurse to give the following stock
July 8-13 Sr. High Camp *Maximum cabin cost $425 (cabins sleep 8-
medications to my camper if needed (circle any that
10).
apply)
July 15-20 Junior Camp
*Day camp is included in the cost of Family
Advil Tylenol Benadryl Zyrtec Tums
July 22-27 Jr. High Camp Camp
Pepto-Bismol Milk of Magnesia Robitussin
Additional guests will be charged the per
September 6-7 Ladies’ Retreat
person rate, even if they are staying in your Reason___________________________________________
September 13-14 Men’s Retreat cabin.
Do you have any physical restrictions that would limit
Primary Day Camp your participation in camp activities? ___Y ___N
September 20-21 Youth Retreat
PDC is a very special week for us. We invite If so, please
October 6 Music Festival
you to bring a busload of kids from your describe____________________________________________
church for Bible time, snacks, crafts, playtime,
October 15 Senior Saints Color Tour
swimming and many other fun activities. ____________________________________________________
Primary day campers should bring a change
of clothing, swimsuit and towel, shoes and
money for snacks and crafts. Give the latest dates your child has had the following
Cost of camp ($55) includes lunch and immunizations:
swimming
________Polio ________Diphtheria ________Mumps
________Rubella ________Chicken Pox
________Tetanus
Family
Physician____________________________________________
Phone#_____________________________________________
Date of last physical
exam________________________________
