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
Camper's First Name
Date of Birth
Male or Female
Grade Completed by July 2018
Address, City, State and Zip
Phone Number (Cell)(XXX) XXX-XXXX
Day Phone (if different) (XXX) XXX-XXXX
Evening Phone (if different) (XXX) XXX-XXXX
Zion Countryside Church
St. Paul UCC
Emergency Contact Name
Relationship to Camper
Emergency Contact Phone (XXX) XXX-XXXX
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.
PLEASE LIST ANY KNOWN ALLERGIES.
PLEASE LIST SPECIAL ASSISTANCE OF ANY TYPE.
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.
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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