2019 DayCamp Registration: DAYTIME Participants Only

Register those who will ONLY participate in our Thursday & Friday Daytime Program on this form.


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OVERNIGHT participants must register by following the appropriate link on Cornerstone's Website.


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Children Must Be...:
Entering Kindergarten,
At Least 5 Years Old, or
Be accompanied by a parent or guardian while at DayCamp.

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Daytime Program Schedule:

* * * Program Start Program Finish
Time @ Camp Time @ Camp

Thursday, July 4
& 9:30 AM 1:00 PM
Friday, July 5


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* * * If you need help with presentation to and from camp,
please be sure to indicate that on the form below.


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


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Payment:
DayTime Participants -

$10.00 total due no later than the start of the two-day program.


Registration, Medical Release, Consent, and Emergency Contact
ALL Participants must be registered. Only ONE Participant per form.
Name of Adult Registering this Participant *
Your answer
Phone Number of Adult Named Above *
Your answer
Participant's Full Name *
Your answer
Sex (check one) *
Required
Age - On July 3, 2019 (Must be 5 or Accompanied by parent or guardian) *
Your answer
Last School Grade COMPLETED Prior to July 3, 2019 (if applicable)
Your answer
Home Address *
Street Address, City, State, Zip Code - - - Or, indicate "Same as [name of someone already registered]".
Your answer
Telephone *
Your answer
Email Address (Adult Registering this Child) *
Your answer
Emergency Notification Information
Must be completed for ALL campers, regardless of age.
Emergency Contact Name *
Your answer
Relationship to Participant *
Your answer
Emergency Contact Address *
Street Address, City, State, Zip Code - - - Or, Indicate "Same As Camper" if Applicable.
Your answer
Emergency Contact Daytime Phone *
Your answer
Emergency Contact Evening Phone *
Your answer
Secondary Contact if Above Cannot Be Reached *
Your answer
Relationship to Participant *
Your answer
Phone *
Your answer
Authorization to Participate, Consent to Photograph, and Medical Release
I hereby grant my permission for the above named Participant 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. *
Your answer
Authorized Medications and Other Pertinent Health Information
Must be completed for ALL campers.
Participant's Full Name *
Your answer
List any health problems, medical conditions, or other physical limitations the participant may have (diabetic, allergies, in need of handicap accessible facilities, etc.) *
Your answer
Has this participant recently been under a doctor’s care? If so, please explain.
Your answer
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.
Your answer
Will participant be taking prescription medications at camp? *
Required
If so, please list type of medication, dosage, time of day it is taken, and who will be responsible for administering it (Participant or Adult Leader).
Please list each medication on a separate line.
Your answer
Transportation To / From DayCamp
Please indicate how your child will be transported to / from DayCamp *
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