2012 Summer Camp Registration Form.pdf

2012 Bethlehem Youth Summer Camp REGISTRATION FORM

Camp Price: $275 (checks payable to Bethlehem Baptist) Registration closes on May 30.

For information on Financial Aid (either need based scholarships or multiple family member discounts), please contact Kevin Dau at 612.338.7653 x493 or campsretreats@hopeinGod.org.

Enter Approved Scholarship or Multiple Child Discount Amount Here $__________

To use funds from a student account, please indicate the amount here $____________ To verify funds, contact Betty Dodge at betty.dodge@hopeinGod.org or at 612.338.7653 x490.

Figure Amount Due: $275 camp fee +$3.00 per non-camper attending Grand Finale Feast (max. $12). Subtract any financial aid, and/or student account money used. Total Amount Due: $____________ (Make check for this amount)

Mail or deliver form to Kevin Dau at 720 13th Avenue South, Minneapolis, MN 55415. Paper Registrations received or arriving after May 30 will be placed on our waiting list. You must submit a form and payment to be placed on the waiting list.

Registrant’s Name (use a separate form for each child)
Address
City, State, ZIP
Phone
Email for Registration Confirmation

Grade in Fall 2012    7    8    9
Gender    M    F
Campus I attend    North    Downtown    South    Visitor
Transportation TO CAMP    Bus That’s Provided    Driving Separately
Transportation FROM CAMP    Bus That’s Provided    Pick Up Separately
If “Pick Up Separately” List the name of who we should expect to pick up:

T-Shirt Size    YS    YM    YL    S    M    L    XL

The feast will immediately follow our return from camp (approx. 5:30PM). The entire family is welcome to join us for a cookout meal, testimonies, a final word from our speaker and camp pastor. We expect this to be a special reunion for families.

Cost is $3.00 per person with a max of $12. How many members of your family will be attending the feast (not including campers):____

Cabin Mate Requests (up to 2):
Visitors: Please list who invited you.

Parental Consent & Medical Treatment Form

Bethlehem 2012 Youth Summer Camp
I, the undersigned parent or guardian of the child listed below, who is a minor, do hereby authorize adult workers with the youth of Bethlehem Baptist Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named below, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such service.

I agree to transport my child home in a timely manner upon being contacted as a result of disciplinary action by the director and pastor(s) of this camp.

Furthermore, by registering my child, I consent to the use of any visual media my child appears in for informational and promotional purposes and distribution to camp and church staff and participants and their families.

Thanks for registering for camp! Please download and read our Need-To-Know documents for further details at hopeinGod.org/document/2012-youth-summer-camp

Insurance Company
Policy Number/ID/Group Number

Print Name of Authorizing Parent
Signature of Authorizing Parent

Medical Info
List any FOOD ALLERGIES
Medical Alerts, Other Non-Food Allergies, Activity Restrictions (Give Details):
TTetanus Booster Current    Yes    No
Allergic to:
Penicillin    Yes    No
Sulfa Drugs    Yes    No
Insect Stings    Yes    No
Emergency Contact Name and Number (other than parents):