5 Star Bible Camp 2018 Camper Registration Form
5 Star Bible Camp is July 16—July 22, 2018 at Camp Jefferson. This year's theme is "Shipwrecked - Rescued by Jesus!"
The camp is free and all children are welcome!

Pre-K - 3rd Grade Camp: July 16th - July 18th, 1:00 pm to 6:00 pm. Registration is Monday, July 16th at 12:30 pm. (No
meal provided - Snack only) Open to children 5 years old (by July 16, 2018) - 3rd grade. (4-year-old children welcome
with an attending parent/guardian.)

4th - 6th Grade Camp: July 16th - July 18th (Overnight) Registration is Monday, July 16th at 8:30 am. Open to children who
have completed 4th-6th grades.

7th - 12th Grade Camp: July 19th - July 22nd (Overnight) Registration is Thursday, July 19 at 9:00 am. Open to youth who
have completed 7th-12th grades.

All registrations are due by June 30, 2018.
Camper's Last Name
Your answer
Camper's First Name
Your answer
Age
Date of Birth
MM
/
DD
/
YYYY
Male or Female *
Grade Completed by July 2018 *
Address, City, State and Zip
Your answer
Phone Number (Cell)(XXX) XXX-XXXX
Your answer
Day Phone (if different) (XXX) XXX-XXXX
Your answer
Evening Phone (if different) (XXX) XXX-XXXX
Your answer
Church Affiliation *
Emergency Contact Name
Your answer
Relationship to Camper
Emergency Contact Phone (XXX) XXX-XXXX
Your answer
WHICH “OVER-THE-COUNTER” MEDICATIONS MAY THE CAMP NURSE DISPENSE TO YOUR CHILD IF DEEMED NECESSARY? (Tylenol, Ibuprofen, Benadryl, ointments, etc.) Please list. The nurse will have to call you for permission if this area is not marked and your child requires any medications.
Your answer
PLEASE LIST ANY KNOWN ALLERGIES.
Your answer
PLEASE LIST SPECIAL ASSISTANCE OF ANY TYPE.
Your answer
PLEASE BRING A LIST OF MEDICATIONS TO BE DISPENSED AT CAMP.
In the event of illness or accident, if the parent or guardian cannot be reached, I authorize the 5 Star Bible Camp personnel to consent to any diagnosis, examination, treatment, or hospital care for my child which is deemed advisable by and is rendered under the supervision of a physician. I release the involved churches, Camp Jefferson and their agents from responsibility in the case of accident or illness in connection with any camp activities. *
Required
I give my permission for photographs and/or video to be taken of my child while engaged in camp activities and for these images to be used in the media, social media, or websites and in promotional materials of the camp.
T Shirt Size
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