Registration Form — Camp Connect

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Camp Connect

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Student Memories

Camp Connect

What's Happening

More Information

Student Memories

What's Happening

More Information

Student Memories

Camper Registration

Please fill out this form entirely. Camper registration and liability form must be completed in order for camper to participate.

BASIC INFO:

Student (Camper) Name *

First Name

Last Name

Camper Birthdate *

MM

DD

YYYY

Gender (Male or Female) *

Grade Just Finished *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Parent/ Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Parent/Guardian Email *

Shirt Size (Adult Sizes): *

Small

Medium

Large

X-Large

XX-Large

XXX-Large

XXXX-Large

Church Attending With: *

First Baptist Church Killeen

First Baptist Church Corsicana

New Sunset

Pendleton Community Church

The Journey Church

Skyline

Airway Baptist Church

Christ Community Church

ADVANCED:

Roommate Choice #1 *

Roommate Choice #2 *

Roommate Choice #3 *

Family Group Friend #1 *

Family Group Friend #2

MEDICAL

Emergency Contact Name: *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

Emergency Contact Name: *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

Doctor/Physican Name: *

First Name

Last Name

Doctor/Physician Phone: *

(###)

###

####

Are you insured? *

If so with who?

Is your Camper current on tetanus and immunization shots? *

Does your Camper have any allergies? *

If so, what?

Allergy Triggers: (Check all that apply)

Food

Environmental

Medication

Pets

Other

If other, please explain:

PLEASE NOTE! Your Camper will be expected to eat the nutritious meals provided unless you fill out the Camp Copass Dietary Form found on their website. Please list the specific allergens, their reactions and general treatment:

Does your Camper carry an epinephrine autoinjector (Epi-Pen)? *

If Yes! You understand that you must provide your Camper required epinephrine autoinjector, inhaler or other specific medication related to the allergy.

Does your Camper require any medication (Prescription and/or Non-prescription) during camp? *

If Yes, please indicate the specific medication, dosage and the times it should be given:

Over the Counter Medication: Please indicate if any of the following over-the-counter medicine that can be given to your Camper while at camp.: *

These will only be given on an "as needed" basis as determined by the Camp Nurse.

Ibuprofen

Tylenol

Benadryl

Cortisone Cream

Pepto Bismol

Tums

Neosporin/Antibiotic Cream

Calamine Lotion

Imodium

Ant Bite Meds/Cream

None of the Above

Has your Camper experienced, or is currently experiencing any of the following conditions: *

Asthma

Diabetes

Heart Conditions

Epilepsy/Seizures

Bleeding Disorders

History of Concussions

Frequent Headaches

Recent Operation or Medical Procedures

Other

N/A

Details of any of the above that may be relevant to your camper's stay at camp:

Please mark any of the following activities that your Camper CAN NOT participate in: *

Zipline

High Ropes Course

Tubing

Canoeing

Swimming

Can participate in all activities

Additional Health Notes: *

LIABILITY:

Do we have your permission to post pictures and videos of your Camper on the camp website? *

If No, please provide a photo of your Camper that we can provide our videographer with so they know the faces of Campers not to be used in any camp/promo videos.

Yes

No

Parent Name (Electronic Signature) *

Please sign your name in agreement for use of photos/video.

First Name

Last Name

Student Name (Electronic Signature) *

Please have your Camper sign their name for verification their photos/videos can be used.

First Name

Last Name

Date

MM

DD

YYYY

PLEASE NOTE:

Parents and students/campers must read and sign a physical copy of the CONNECT CAMP ASSUMPTION OF RISK, WAIVER OF LIABILITY, and PARENT/GUARDIAN PERMISSION FORM in order to attend camp. After submitting your registration, please return to the registration page to access the link to the Camp Connect Liability Form. This form must be printed and submitted to your student’s pastor.

Thank you for completing the Camp Registration. Don’t forget to print a copy of the Camp Connect Liability Form and submit to your Youth Pastor/Pastor before the camp registration deadline. This year campers are also required to complete a liability form through Camp Copass. Both links can be found on the registration page.

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