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Camp Rock Camper Registration
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Which Camp Will Your Camper Be Attending? (check just one) *
Required
Camper - Last Name *
Your answer
Camper - First Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent - Cell Phone *
Your answer
Parent - Alternate Phone
Your answer
Parent - Email Address *
Your answer
Camper's Birth Date *
MM
/
DD
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YYYY
Gender *
*** Grade on January 2019 *** *
Your answer
Parish You Attend *
Your answer
Shirt Size (Adult Sizes Only) *
Camper's Medical Information
Please list medications, allergies, medical conditions, physical limitations, diet restrictions, and other important information we should be aware of:
*
Your answer
Medication Requirements
All medications, including over the counter (i.e. Tylenol, aspirin, Benadryl, etc.) are to be turned in to the camp nurse upon registration. Medication should be in it’s original container and clearly marked with the young person’s name. Please put the container in a clear zip-lock bag along with instructions indicating
dosage and times.
Application Permissions *
By checking this box and submitting this registrations form I give permission for my child to attend the Jr. High summer camp located at Dickson Valley Camp and Retreat Center, Newark, Illinois and sponsored by Joyful Hope Presentations to be held on dates check at the top of this page. I hereby release and indemnify Joyful Hope Presentations along with its staff and volunteers from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this program. If needed for health reasons , I give permission for my child to be evaluated, diagnosed, treated, and/or given medication in accordance with standard medical practice by licensed medical personnel. I agree to accept all financial responsibility as a result of scheduling medical treatment and transportation. I understand that once my child is at camp my child shall remain for the entire camp unless emergency should require my child’s early dismissal and that if my child fails to cooperate with camp rules and regulations they may be immediately dismissed from the event and it is my responsibility for picking up my child as necessary.
Required
Parent First Name *
Your answer
Parent Last Name *
Your answer
Emergency Cell Phone # *
Your answer
Emergency Contact Full Name *
Your answer
Emergency Contact Cell # *
Who can we call in an emergency if you are not available?
Your answer
Regular Physician's Name *
Your answer
Physician's Phone # *
Your answer
Insurance Company *
Your answer
Policy Holder's Name *
Your answer
Policy Number *
Your answer
Mandatory Forms
You may download from our web site the mandatory “Camper Code of Conduct” and the “Medication” forms that are due a minimum of two weeks prior to camp. If your camper is taking prescribed medications the “medical Form must also be signed by the prescribing doctor.” You must sign and submit a Medication form even if your camper is not taking any prescribed medications. Please list the over-the-counter medications you provide your child and sign the bottom of the form. Online you can sign up to volunteer during camp and register your camper for free busing.
Cost of Camp
The total cost of the camp is $300 per camper per camp. A $80 nonrefundable deposit must be made for your camper registration to be accepted. The $220 balance is due 30 days
prior to camp. If you are sending more than one camper or your camper will be going to both camps, pay the $80 deposit for each and then contact John via email at john@camprock.me for any available discounts. Failure to pay or submit forms by these dates voids your camper’s registration.
*** Payments can be made using our PayPal donation button on the front page of our web site otherwise you can send a check made out to “Camp Rock” PO Box 484, Batavia, IL 60510.
Scholarship Requests
Scholarship Requests: No one will be denied participation because of justified inability to pay. Please submit your request for financial assistance to John at john@camprock.me. Be sure to include in your request exactly why your family is unable to pay a portion of the fee and how much of the remaining balance you need help with. All application are required to pay the $80 nonrefundable deposit.
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