Burnt Cabin Christian Camp- Perkins Session (June 11-16, 2023)
This form acts as a camp application to attend Burnt Cabin Christian camp on June 11-16 of 2023. You must fill out one form for each camper attending.
Sign in to Google to save your progress. Learn more
Last Name of Camper
First Name of Camper
Clear selection
Date of Birth
Age (We accept children ages 9 - up)
Grade starting this Fall (We accept kids starting 4th grade this Fall)
Parents' or Guardians' Names (please write at least two)
Parents' or Guardians' Cell Phone (please write at least two)
Additional Emergency Contact Name and Number.
Home Church
T-Shirt Size (Choose one below, if you would like to order more please see our online store at... The cost is $10.00.
Payment: (We prefer online payments at https://www.perkinschurch.org/give )
Clear selection
Total amount I am responsible for paying: (The cost for the camp is $240, not counting the cost of the shirt. Please indicate if a 3rd Party, such as a church, will be paying a scholarship for your child. 
Clear selection
Medication: List below with dosage instructions. (Medication will be administered by our Camp Nurse.)
Physical Limitations
Name of Primary Care Doctor
Phone Number
Date of Last Tetanus Shot.
Insurance Company: (Please send this card or a picture/copy front and back to camp with your child.)
Policy Number
Policy Holder Name
Insurance Phone
I hereby grant permission for the person named above to attend Burnt Cabin Christian Camp. I give permission for the Camp Director to authorize routine treatment of non-emergency care in cases of injury or illness. In any emergency, I understand that every reasonable effort will be made to contact me. In the event I am not reach promptly, I hereby give my permission to the physician selected by the Camp Director to hospitalize and secure proper treatment, including surgery, for my child at my expense to the extent not covered by the camper's insurance. I release Burnt Cabin Christian Camp and all camp personnel from any liability arising from all routine or emergency care. My initials below present my legal signature. (initial below with date)
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy