2019 Cornerstone Camp Registration: Overnight Participants

PLEASE ONLY REGISTER CAMPERS WHO WILL BE STAYING OVERNIGHT ON THIS FORM.


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Daytime program participants can be registered by following the link on Cornerstone's Website.


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Overnight Camping:
Begins: Wednesday, July 3 at 5:00 PM
Ends: Saturday, July 6 at 12:00 PM


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Camp Location:
Wisconsin Church of God Camp & Retreat, Rock Springs, WI


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Payment:
Overnight Campers

Pre-Registration with $10.00 Non-Refundable Deposit due by June 2, 2019
Final Payment due no later than June 16, 2019


Registration, Medical Release, Consent, and Emergency Contact
ALL Campers must be registered. Only ONE Camper per form.
Camper’s Full Name *
Sex (check one) *
Required
Age - On July 3, 2019 *
Last School Grade COMPLETED Prior to July 3, 2019 (if applicable)
Home Address *
Street Address, City, State, Zip Code - - - Or, indicate "Same as [name of someone already registered]".
Telephone
Email Address *
Will camper be staying in Dorm, RV, or Tent? (Choose one) *
Emergency Notification Information
Must be completed for ALL campers, regardless of age.
Emergency Contact Name *
Relationship to Camper *
Emergency Contact Address *
Street Address, City, State, Zip Code - - - Or, Indicate "Same As Camper" if Applicable.
Emergency Contact Daytime Phone *
Emergency Contact Evening Phone *
Secondary Contact if Above Cannot Be Reached *
Relationship to Camper *
Phone *
Authorization to Participate, Consent to Photograph, and Medical Release
I hereby grant my permission for the above named Camper to participate in the DayCamp/Family Camp/Summer Retreat organized and conducted by Cornerstone Missionary Baptist Church. I give permission for Cornerstone representatives to photograph and video record myself and/or my child as a part of program activities, and I allow any photos or videos that include me and/or my child to be published at the discretion of Cornerstone Missionary Baptist Church representatives. Further, I hereby grant permission for any adult participant of said program to seek and authorize emergency medical attention and treatment on behalf of myself in the event I become injured or incapacitated, and/or my child in my absence, and hereby release Cornerstone Missionary Baptist Church and its members/assigns from any and all liability associated therewith.
Please initial in the box below with the understanding that doing so constitutes your signature as an Adult Camper or the Parent/Legal Guardian of a Minor. *
Authorized Medications and Other Pertinent Health Information
Must be completed for ALL campers.
Camper's Full Name
List any health problems, medical conditions, or other physical limitations the camper may have (diabetic, allergies, in need of handicap accessible facilities, etc.)
Has this camper recently been under a doctor’s care? If so, please explain.
The information supplied in this form is true and complete to the best of my knowledge. *
Please initial in the box below with the understanding that doing so constitutes your signature as an Adult Camper or the Parent/Legal Guardian of a Minor.
Will camper be taking prescription medications during camp? *
Required
If so, please list type of medication, dosage, time of day it is taken, and who will be responsible for administering it (Camper or Cabin Sponsor).
Please list each medication on a separate line.
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