Travel Camp Registration

RM_Stats
Parent Information
First Name (Parent)^*
Last Name (Parent)^*
Address 1^*
Address 2
City^*
State^*
Zip Code^*
Email Address^*
Enter Parent Email Address
Cell Number^*
Enter Parent Cell Number
Home Number
Work Number
Camper Information
First Name^*
Last Name^*
Gender^*
Male

Female

Address 1
Address 2
City
State
Zip Code
Email Address^*
Enter Camper Email Address
Cell Number^*
Enter Camper Cell Number
Birthdate^*
Age as of 7/10/23^*
Grade Fall 2023^*
High School^*
Home Church & Pastor Name
Leave blank if you do not have a home church
What t-shirt color would you like?^*
T-shirt Size^*
Medical Information
Does the camper take medication? Either prescribed or or over-the-counter.^*
Does the camper have any allergies?^*
Date of Last Tetanus Shot - (to the nearest year is ok)^*
List any activity or swimming limitations^*
Check any that apply:^*
Asthma

Carries an Inhaler

Diabetic

Hay Fever

Heart Problems

Heat Exhaustion

Hyperactivity

Stomach Problems

Sunburns Easily

Acid Reflux

None

Other
Doctor's Name^*
Doctor Phone^*
Medical Insurance Provider^*
Medical Insurance Policy Number^*
Name of Insured^*
Insurance Phone Number^*
Picture of insurance card (or send in mail after registration)

Emergency Contact (Someone we can contact if you are unavailable)^*
Relationship to Camper?^*
Phone Number^*
Medical Consent and Release^*
Permission Granted
In the event of a medical emergency, and I cannot be reached during my child’s participation at CRC, I give permission to the doctor selected by CRC to secure treatment, hospitalize, perform surgery, and prescribe medications as deemed necessary to protect my child's health and well-being. I also authorize CRC to administer any medication, whether brought by the camper or available here (such as acetaminophen, ibuprofen, or other non-prescription drugs) as deemed advisable by the camp staff or a doctor, and to administer first aid when necessary. Further, in signing this form, I hereby certify that I give permission for my son or daughter to participate in the camping program of CRC. I release CRC, its agents, employees, or representatives from all claims or actions from the above named minor child participating in camp.
Liability Waiver
I accept
In consideration of my participation in any way in the events and activities of Christian Resource Center, the undersigned acknowledges, appreciates, and agrees that: The risks of injury and illness (ex: communicable diseases such as MRSA, influenza, and COVID-19) from the activities involved in these programs are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness do exist; and, FOR MYSELF, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, and assume full responsibility for my participation; and willingly agree to comply with the programs stated and customary terms and conditions for participation. I HEREBY RELEASE AND HOLD HARMLESS Christian Resource Center; its directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), with respect to any and all injury, illness, disability, death, or loss or damage to person or property incident to my involvement or participation in these programs to the fullest extent permitted by law. I HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releases from any and all liabilities incident to my involvement or participation in these programs to the fullest extent permitted by law. I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to rules and regulation, and accept them as a participant. By registering for camp, you are allowing CRC to use photographs and videos in promotional material.
You are registering for Travel Camp 2023
A $50 deposit is required to complete your registration. Payment may be submitted online or via mail. If paying via mail, choose "Pay Offline" and send check to: CRC 603 K Road Giltner NE 68841 Total cost is $575 (scholarships are available upon request). You are welcome to pay any portion of the full amount at this time if you like! Balance is due on June 30. Deposits are non-refundable after June 26.
Travel Camp Deposit^*
Select a payment method^*

Pay Offline