Camper Registration

Name (required)

Email (required)
Upload a recent photo

AddressCityStateZip Code

Parent/Guardian name(s) Home Phone

Grade level Fall 2016


Do you attend church? YesNo Church Affiliation

Have you attended camp before? T-Shirt Size

Check all that apply:
I consider myself a ChristianI believe in God and sometimes prayI want to learn more about GodGod is not a part of my life

DISCLOSURE OF SPECIAL HEALTH CONDITIONS: The following is a list of my child’s special health conditions and needs, which event staff needs to be aware of (list here such things as medications, history of seizures, heart condition, diabetes, motion sickness, allergies, etc.

RELEASE OF LIABILITY REGARDING SPECIAL HEALTH CONDITIONS: I submit that the above mentioned special health conditions and
instructions are needed for my child while at the event. I understand that, although event personnel will seek to help accommodate these special conditions, such as by giving medications and/or by seeking to take appropriate precautions etc., nonetheless, by sending my child to the event with these conditions:
- I acknowledge that I understand the event is not equipped to monitor or supervise such special conditions or needs as would the parent if he/she were present.
- I certify it is safe for my child to participate in all event activities notwithstanding the special conditions, and notwithstanding any possible lapse
in medication, or possible interaction with other people or circumstances that may affect the special conditions.
- I release and indemnify the event from all claims and liability stemming from the special conditions, including, without limitation, any claim, illness,
or injury, resulting from the event’s failure to properly administer medicines for the special conditions, failure to recognize a situation which might
be potentially harmful to a person with the special conditions, or failure to recognize the onset of an episode of the special conditions.
PERMISSION TO SECURE EMERGENCY SERVICES: I give permission to event staff to secure usual and customary medical and/or legal services for my child if needed in an emergency circumstance at the event. I as parent/guardian will be responsible for the costs of such services
if not covered by my insurance.
INSURANCE COVERAGE: My child is covered by medical insurance: YesNo
If yes, list the name of the insurance company: and the policy number:.
Attach copy of insurance card. I understand that if my child has no health/accident/medical insurance coverage, I will be responsible for the
payment of all expenses which may be incurred due to treatment at the event of an illness or injury. Please scan or take a photo of your card and upload here.

EMERGENCY CONTACTS: During the event I may be contacted day or night as follows:
Name Phone Number
If I cannot be reached in an emergency, the following two individuals will know of my whereabouts and/or have my permission to represent my wishes
regarding medical or other emergency care for my child:
Emergency Contact 2 Phone number

Printed Name:

By submitting this registration, I hereby give Base Camp NW, a chartered entity of Grace Communion International permission to have my child participate in all activities at camp, unless specifically limited above. I give permission for my child to be transported off the camp property to camp-related activities. Base Camp NW may use any photos and video taken of the applicant at our summer camp event in their publications or those of their sponsor, Grace Communion International.