Rural Bible Crusade of Wisconsin Camper Registration/Health Form
Registration for Rural Bible Crusade of Wisconsin Camp and Retreats - Please fill out a form for each child that will be attending.

“The earth is the Lord's and the fullness thereof, the world and those who dwell therein, for He has founded it upon the seas and established it upon the rivers.”
Psalm 24:1-2
Email address *
Camper's First Name *
Your answer
Camper's Last Name *
If registering more than one child on this form, this information must be the same for every child you are registering.
Your answer
Camper's Date of Birth *
MM
/
DD
/
YYYY
Camper's Age *
Your answer
Camper's Gender *
Camper's Full Address (Address, City, State, and ZIP) *
If registering more than one child on this form, this information must be the same for every child you are registering.
Your answer
Please list Custodial Parent(s)/Guardian's Name, Home Phone and Cell Phone *
If registering more than one child on this form, this information must be the same for every child you are registering.
Your answer
Please list an additional emergency contact. Please include: Name, Relationship to Camper, Home Phone and Cell Phone *
If registering more than one child on this form, this information must be the same for every child you are registering.
Your answer
Please list: Insurance Company, Phone number, Address, City, State, Zip, Policy Holder Name, Date of Birth, Relationship to camper, Policy Number, and Group Number *
If registering more than one child on this form, this information must be the same for every child you are registering.
Your answer
Are the camper's immunizations up to date? *
What is the date of the camper's last tetanus booster? If known, please specify (mm/dd/yyyy) in "other" *
Does the camper have any medication allergies? If yes, please specify in other. *
Required
Does the camper have any food allergies or special dietary needs? If yes, please specify in other. *
Required
Does the camper have any of the following: (Check all that apply) In the "other" box please explain any that have been checked. *
Required
Will the camper be bringing any prescription medications to camp? If yes, please list them in the "other" area. *
Required
Will the camper be bringing over the counter medications to camp? If yes, please list them in the "other" area. *
Required
Will the camper be bringing an inhaler to camp? *
Will the camper be bringing an epi-pen to camp? *
Please indicate what your child has done to earn FREE RBC camp. THIS IS FOR SUMMER CAMP ONLY! *
Rural Bible Crusade of Wisconsin Acknowledgment & Assumption of risk waiver and release..."Upon careful reading and consideration I (Parent/Guardian), ____________ of (Child) _____________ recognize that some activities carry the risk of injury." *
Please type "(your name) and (child's name)" below, under "other".
Required
Would you like to register a second child? The second child MUST HAVE THE SAME LAST NAME AS THE FIRST CHILD, the same health insurance information, home address, custodial parent(s)/guardian, and emergency contacts as are already listed on this form. *
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