Christian Conference Center 2017 Summer Camps

Every camper must fill out a registration.  (This includes each person registering for Family Camp or Grand Camp).  If you have any questions, call the Christian Conference Center at 641.792.1266.  Monday, MAY 15th is the LAST DAY for early bird registration. After that there will be a $25 late registration fee.  Thank you!

Parent/Guardian with legal custody

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Secondary Emergency Contact

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Choose Your Camp & Payment Options

  [$15.00]

For Grand Camp and Family Camp Only: If staying in a Lodge Room, there is an additional $40 fee, call the Conference Center office for availability: 641-792-1266




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Billing Information

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Insurance

Allergy Information

 

 

 

 

 


Diet/Nutrition

 

 

 


Vaccination History

Has the camper had or been vaccinated for:


Emotional/Social Health

Has the Camper:


Restriction Information

 

 


General Questions

Has/does the participant:


Medication

"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. All medications are collected, stored, and distributed by camp health care personnel. Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring only enough medications to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

 


Medication Treatment

 

 

 


Healthcare Providers

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Authorization Information

You will be contacted if:
Your child is exposed to a communicable disease
Outside medical attention is necessary (e.g., if we transport your child to a hospital/Dr. office)
Your child is having discipline problems that jeopardize the safety of others
What have we forgotten to ask? Please provide any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program.

The undersigned person represents that he/she is the custodial parent/legal guardian of the above identified participant. The camper has my/our permission to attend the camping season from ___________ to ___________ (dates) at The Christian Conference Center. This permission given by me/us with full knowledge of the conditions and activities contemplated during each session (see uppermidwestcc.org for more information). The participant has no physical or mental disabilities that would impair their participation except as noted above. I/We acknowledge, agree to, reconfirm and incorporate herein by reference the Release of Liability signed by me/us which is attached hereto. I also understand that the information provided on this form will be kept confidential and shared only as necessary to provide care of the participant.
I understand that camp insurance is a supplemental policy only. It will pay whatever my own insurance doesn’t cover (deductible or over) up to the limit of the policy. If medical (sickness, injury) care is needed, billing will be sent to the parent/guardian who will be responsible for direct payments to physical, hospital, clinic, etc.
The participant is currently taking only medications listed above. The camper who has no allergies known to me/us except as noted on this form. The health information/history is correct as far as I/we know. In the event of illness or injury, I/we authorize the camp, physician and or hospital to undertake such treatment of and perform such services (including surgical) for the participant as are reasonably indicated by the circumstances.


Name Amount  

 

  

CVV2

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