Kids' Camp 25': Camper Registration Form

This form MUST be completed and signed by a parent or guardian & submitted before the child is allowed to stay at camp. Please fill out one form per camper.

Child's Info

Name

Birthdate

Gender

Female Male

Last Grade Completed

3rd 4th 5th 6th

T-Shirt Size

ALL medications MUST be filled prior to camp and given to the nurse in their original prescription or over the counter bottles at the time of registration. Please list any and all medical information the camp nurse should have (for example: allergies, prescribed treatment, major illnesses and medical conditions, medications taken by the camper, dosage and frequency of medication).

Please List Any Medications Info. (If none, type "NONE")

Any Food Allergies or Dietary Restrictions? (If none, type "NONE")

Emergency Contact (1) - please include Name, their relationship to the Camper & Phone number

Emergency Contact (2) - please include Name, their relationship to the Camper & Phone number

Physician's Name & Phone Number

Insurance Carrier & Policy Number #

Date of Last Tetanus Shot

Primary Parent/Guardian Contact Info

Parent/Guardian Name

Phone

This address will receive a confirmation email

Address

Medical Release & Acknowledgments

Please READ and ACKNOWLEDGE the following statements:

I understand the 2024 IBSA Camps require good physical condition. The Camper may participate in all activities, including sports.

Yes No (Indicate possible physical concerns at the end of this form)

I give permission to the Camp Nurse to give my child an appropriate dose of Acetaminophen (i.e. Tylenol) or Ibuprofen (i.e. Motrin) when determined to be needed.

Yes No

READ and ACKNOWLEDGE the following statement:

I, the Parent/legal guardian of the child mentioned above, a minor, hereby acknowledge by TYPING MY FIRST and LAST NAME BELOW, that said minor is under my care, custody, and control. I hereby give my child, the said minor, my express permission to attend one of the 2025 IBSA Summer Camps.

I further expressly grant my permission for my child to participate in all activities of said camp. I understand that my child may be photographed and video-taped at camp for promotional purposes. These photos or videos will not be sold for profit.

I have listed said minor’s physical defects or medical problems that may need attention. In the event there arises an emergency, necessitating medical or surgical attention, I hereby consent and give my permission to the Growth Team of the Illinois Baptist State Association, or its representatives, or the camp nurse or counselors, or any attending physician to make such decisions and to perform such medical treatments, and/or surgery upon said minor which may, in their sole discretion be necessary and proper under such circumstances. I do release, acquit, discharge, and covenant to hold harmless the Growth Team staff personnel, camp nurse or counselors, the Illinois Baptist State Association, or its representatives, or any attending physician to make decisions.

I have read and acknowledge the statement above.

Yes

First and Last Name of Parent/Legal Guardian

Date of Acknowledgment Signature

*Electronic signatures are regulated by the Uniform Electronic Transactions Act. Legally, an "electronic signature" can be the person’s typed name, email address, or any other identifying marker.*

Any Other Information We Need to Know?

Please detail any other information or concerns not mentioned above.

Payment

You may pay the $180 registration fee below - or - opt to pay in the church office by Thursday, June 5th, 2025. The church office is open Monday-Thursday, 8am-4pm.

If you would like to request a scholarship, please select the "Pay Later" option below and send an email to Pastor Ryan at ryan@ibcbenton.com, indicating your request.

Pay Now or Later in the Church Office?

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Kids' Camp 25': Camper Registration Form

Description

Please Fix the Following