2018 Cornerstone DayCamp Registration: Daytime Participants

USE THIS FORM TO REGISTER THOSE WHO WILL ONLY PARTICIPATE IN THE DAYTIME PROGRAM.


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Overnight camping participants can be registered by following the link on Cornerstone's Website.

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Children must be...
Entering Kindergarten,
At least 5 Years old, or
Be accompanied by a parent or guardian while at DayCamp.
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Daytime Program Schedule:

* * * Pick-Up Time Program Start Program Finish Drop-Off Time * * *
In Reedsburg Time @ Camp Time @ Camp In Reedsburg

Thursday, August 16
& 9:00 AM 9:30 AM 1:00 PM 1:30 PM
Friday, August 17


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* * * Pickup & Return for Daytime Program Participants May Be Available in Reedsburg -

Details (where & when) will be sent as soon as available - assure your email is correct.

Watch Cornerstone's Website & Facebook page for updates or contact Cornerstone for details.


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

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Payment:
Daytime Only Participants -

$10 total fee due no later than the first day of the 2-day program.

Registration, Medical Release, Consent & Emergency Contact
ALL DAYTIME Participants must be registered. Only ONE Participant per form.
Participant’s Full Name *
Your answer
Sex (check one) *
Required
Age as of 8/15/18 (Must be at least 5 years old)
Your answer
Last School Grade COMPLETED as of 8/15/18
Your answer
Home Address
(Street Address, City, State, Zip Code)
Your answer
Telephone
Your answer
Email Address (Adult's if registering child) *
Your answer
Emergency Notification Information
Must be completed for ALL Participants, regardless of age.
Emergency Contact Name *
Your answer
Relationship to Participant
Your answer
Emergency Contact's Address
(Street Address, City, State, Zip Code)
Your answer
Emergency Contact's Daytime Phone *
Your answer
Emergency Contact's Evening Phone *
Your answer
Secondary Contact if Above Cannot Be Reached
Your answer
Relationship to Camper
Your answer
Address
(Street Address, City, State, Zip Code)
Your answer
Daytime Phone
Your answer
Evening Phone
Your answer
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 Participant or the Parent/Legal Guardian of a Minor. *
Your answer
Authorized Medications and Other Pertinent Health Information
Must be completed for ALL Participants.
Participant's Full Name
Your answer
List any health problems, medical conditions, or other physical limitations the Particpant may have (diabetic, allergies, in need of handicap accessible facilities, etc.)
Your answer
Has this Participant recently been under a doctor’s care? If so, please explain.
Your answer
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 Participant or the Parent/Legal Guardian of a Minor.
Your answer
Will Participant be taking prescription medications during camp? *
Required
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 Sponsor).
Please list each medication on a separate line.
Your answer
TRANSPORTATION TO & FROM DAYCAMP
Cornerstone will be providing free transportation to DayCamp Participants from a location in Reedsburg (precise location to be determined and announced). Will the individual registering utilize the free transportation to be provided? *
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