Please fill this form out completely. If you do not you may be redirected back.It is camp policy that refunds are only given in emergency situations but that DOES NOT include an ADMINSTRATIVE FEE OF $25. Our offices are located at 2600 I-70 Dr. NW Columbia, MO 65202. And you can call us at 573-445-3611. Please note our fee policy: Pre-registration for 2010 is $159 due by April 30th. Early Registration for 2010 is $ 169 due by May 14th. Regular Registration for 2010 is $179 due by June 11th. Walk-ons for 2010 are $199. Filling out the medical insurance is required and your family insurance is the primary insurance.

Which camp are you attending?

Youth Camp 1
Youth Camp 2
Kids Camp

Camp Picture Registration

None
Yes ($5 USD)

Camp DVD Registration

None
Yes ($15 USD)

T-shirt Registration

Church Name and City *

Pastor and Youth Pastor Names *

Camper Registration

Student ($159 USD)
Leader ($130 USD)

First Name *

Last Name *

Street Address *

City *

State

Zip *

Gender

Male
Female

Age

Camper Cell Phone Number *

Email *

Parent or Outside Contact First Name *

Parent or Outside Contact Last Name *

Parent or Outside Contact Driver License Number (Protects your child) *

Parent or Outside Contact Phone (Emergency Contact) *

Does your camper have permission to go offsite during free time?

Is camper a diabetic?

No
Yes

Any special needs we should know about?

Insurance

Yes
No

Carrier *

Policy or Group Number *

Has Camper had diphtheria immunization?

Has your camper had a whooping cough immunization?

Has your camper had a polio immunization?

Has your camper had a tetanus immunization?

Has camper had measles?

No
Yes

Has camper had polio?

No
Yes

Has camper had mumps?

No
Yes

Has camper had chicken pox?

No
Yes

Has camper had scarlet fever?

No
Yes

Has camper had any heart trouble, ear trouble, hernia, or lung trouble?

Has camper had any seizures, asthma, or diabetes?

Has camper had any bleeding, clotting trouble, hypertension or mononucleosis?

Allergies

Are there any restrictions on activities for the camper?

Are there any pre-existing conditions medical personnel would need to be aware of?

Will camper bring medications with them to camp?

No
Yes

Medication 1

Purpose of Med

Frequency and dosage

Doctors Name

Medication 2

Purpose of Med 2

Frequency and dosage 2

Doctors Name and Phone Number

Medication 3

Purpose of Med 3

Frequency and dosage 3

Doctors Name and Phone 3

Medication 4

Purpose of Med 4

Frequency and dosage 4

Doctors Name and Phone 4

* indicates required fields

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