Fall Retreat
October 4-6, 2019
Registration before September 27 = $40


Fees may be paid online at Gasconadecamp.org or mail checks (Fall Retreat in the memo line) to:
Gasconade Christian Service Camp
20500 Ridge Lane
Waynesville, MO 65583
Email address *
Camper Name *
Your answer
Address *
Your answer
Home Church *
Your answer
Camper's current grade *
Required
Dietary restrictions *
Medical Insurance Carrier *
Identification Number, Expiration date, and Family Doctor's name
Your answer
Medications
Please put N/A if no medications are taken. Please list times and dietary needs that accompany the medications
Your answer
In case of Emergency *
Please list contact's name, relationship, and phone number(s)
Your answer
Activity Restrictions *
LEGAL AGREEMENT WITH GUARDIAN & CONSENT FOR MEDICAL TREATMENT OF A MINOR
It is necessary for the parents to assume the responsibility for the applicant. Below is a legal agreement for this purpose which the parent or guardian must sign and return BEFORE THE EVENT.
In the event of an emergency where medical treatment is required, I GIVE MY PERMISSION TO GASCONADE CHRISTIAN SERVICE CAMP staff, or church youth sponsor to authorize any and all medical services and/or procedures, including surgery, if necessary, from a licensed physician. Gasconade Christian Service Camp will attempt to notify the parent/legal guardian prior to the utilization of such services. I, the UNDERSIGNED, agree to hold Gasconade Christian Service Camp harmless against any claim of liability or loss for personal injury, property damage, or economic loss which may arise as a result of the applicant’s participation in the activities of Gasconade Christian Service Camp. I will in no way hold the camp manager, nurse, or staff personally responsible for any accident that might befall the applicant. Further, I will not hold the aforementioned personally responsible for any medical treatment administered to the applicant. *
Signature *
I hereby state that I am the parent/legal guardian of this child stated on this form and hereby give GCSC my consent for my child to attend this event. This is effective for the date listed elsewhere on this form.
Your answer
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