2019 DayCamp Registration: DAYTIME Participants Only

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

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

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

Daytime Program Schedule:

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

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

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

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

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 *
Phone Number of Adult Named Above *
Participant's Full Name *
Sex (check one) *
Age - On July 3, 2019 (Must be 5 or Accompanied by parent or guardian) *
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 (Adult Registering this Child) *
Emergency Notification Information
Must be completed for ALL campers, regardless of age.
Emergency Contact Name *
Relationship to Participant *
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 Participant *
Phone *
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. *
Authorized Medications and Other Pertinent Health Information
Must be completed for ALL campers.
Participant's Full Name *
List any health problems, medical conditions, or other physical limitations the participant may have (diabetic, allergies, in need of handicap accessible facilities, etc.) *
Has this participant 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 participant be taking prescription medications at camp? *
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.
Transportation To / From DayCamp
Please indicate how your child will be transported to / from DayCamp *
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