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

Name (First and Last) *
Your answer
Date of Birth *
Month/Day/Year (i.e. 01/01/2000)
Your answer
Age *
Your answer
Gender *
Full Address (Address, City, State, and ZIP) *
Your answer
Please list Custodial Parent(s)/Guardian's Name, Home Phone and Cell Phone *
Your answer
Please list an additional emergency contact. Please include: Name, Relationship to Camper, Home Phone and Cell Phone *
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 *
Your answer
Immunizations up to date? *
Last tetanus booster *
MM
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DD
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YYYY
Any medication allergies? If yes, please specify. *
Required
Any food allergies? If yes, please specify. *
Required
Any special dietary needs? If yes, please specify. *
Required
Does 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? *
Wisconsin law requires that in order for our health care staff to administer prescription medication to a camper, the bottle MUST be labeled with the camper’s name, name of medication, dosage, frequency and route of administration, name of prescribing physician, date prescribed, possible side effects and precautions. For over the counter medication, the medication must be in its original container and clearly labeled with the camper’s name, the dosage, frequency of administration. BY LAW, MEDICATION MUST BE CORRECTLY LABELED AND IN ITS ORIGINAL CONTAINER. We cannot dispense medication (loose pills) brought to camp in plastic bags or daily dispensers. *
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
You hereby attest as follows: By signature below, I acknowledge that my child will participate in Rural Bible Crusade of Wisconsin activities, programs, and related events. I understand that participation in these activities, programs, and related events is not without risk. I will release, hold harmless, and indemnify Rural Bible Crusade of Wisconsin, its board, staff, and/or volunteers for any harm, injury, or death caused by my child's participation with RBC. I understand that no activity program is absolutely safe and free of risk. Rural Bible Crusade of Wisconsin reserves the right to use any pictures taken of my child at Camp/Retreats to promote the ministry. *
If my child needs medical attention while participating, it is my wish that the treatment be begun while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the Rural Bible Crusade of Wisconsin staff and/or physician believes needed, on the understanding that efforts will continue to be made to contact me. I accept responsibility for all cost related to such treatment. *
I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound to its terms. *
Your answer
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