CR Kids 2023 Camp Registration Form

Kids Camp

Registration Form

May 27th - May 30th, 2024

Child's Name*

First NameLast Name

Date of Birth*

MonthDayYear

Child's Shirt Size*

Grade Completed in 2023-2024 School Year*

Which campus do you attend?*

Has your child ever made a personal decision to follow Jesus Christ?*

YesNoI don't know

Has your child ever been baptized?*

YesNoI don't know

My child is a:

Non-swimmerFair swimmerGood swimmer

Gender*

FemaleMale

Child's name you would like your child to room with

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Parent's/Legal Guardian's Name*

First NameLast Name

Cell Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Child's Height*

Child's Weight*

Allergies

My child can have any of the following OTC medications in accordance with standard label directions. (Check all that apply.)

Emergency Contact #1*

First NameLast Name

Phone Number*

Area CodePhone Number

Relationship to child*

Emergency Contact #2

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to child

Photocopy of the front and back of the insurance card MUST be provided by uploading the file in the space below or in hard copy, no later than April 1.

Please indicate "N/A" in the required fields below if the camper has no insurance.

Photocopy of Insurance Card

Medical Insurance

Insured's Name

Policy #

Phone(Insurance Co.)

Please list ALL medications taken routinely. Bring medications 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.

NAME OF MEDICATION #1

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

NAME OF MEDICATION #2

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

NAME OF MEDICATION #3

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

NAME OF MEDICATION #4

DOSAGE (e.g. 1 pill, 1 puff, 5 mL, 1 TBS)

FREQUENCY/TIME OF DAY (e.g. once daily at breakfast)

Comments

PHOTOGRAPH RELEASE

I hereby give Crossroads permission to use photographs/video/sound of the child named in this registration form for publicity, promotion, news releases, videos, and web use of Crossroads. This might also apply to the written composition or visual art of the person if it is published. This would only be for the church use and marketing promotion.

Parent/Guardian Signature for Photography Release

By checking this box you are authorizing Crossroads Church to charge your credit card.*

Credit Card Authorization

PARENT/GUARDIAN PERMISSION

I hereby give my permission for the child named in this registration form to take part in all Crossroads activities. I hereby give my permission for the designated/approved church representative or sponsor to secure any needed medical treatment for the above named child. I release Crossroads Church from liability for accident or injuries on these trips or from these activities.

I further understand and agree that, in the event that the above named child be involved in any non-Christian or dangerous behaviors/activities, I will pay his or her expenses to be sent home immediately at the discretion of the approved sponsors and/or church representatives.

I have supplied, understood, and agree to all the information contained on this document.

Early Bird Registration$375.00

Total $0.00

Credit Card

Parent/Guardian Signature for permission to participate in all Crossroads activities, and releases Crossroads Church from liability for accidents or injuries on this trip*

Date signed*

HEALTH INFORMATION

MEDICATIONS BEING TAKEN

Credit Card