Camper’s Name Grade entering in the fall ST Zip Secondary Phone M F Birth Date Father’s Full Name Mother’s Full Name Mailing Address City Cell Phone Parent’s Email: Camp Reques ted (Please check one): Youth Camps Registration 2020 Pre-registration deadline: May 15th! Parents: Please completely fill out and sign (please print) Home Church & Church’s City Attending with Church & Church’s City (if different from home church) Family Dr./Phone Insurance Policy# Medications Taken Regularly (Must be in original container) Do we have parent/guardian permission to give: Advil Yes No Tylenol Yes No Current Infectious Diseases or Conditions Allergic Reactions: Bee Stings Food Other Date of Last Tetanus Shot Other medical concerns for your child I hereby give permission for my child to attend IRBC, to participate in all activities, and for any picture/testimony of my child to be used in promotion of the camp. I understand that IRBC has a secondary accident insurance policy with a limit of $5,000 (illness is not covered). I hereby give consent for medical treatment deemed necessary for my child named above. Signature of Parent or Guardian Date In Case of Emergency, Contact Phone Office Use Only: Postmarked: Amount Received $ Check No. Balance Due $ Send registrations in with your church if there is a group coming from your church. If registering individually, mail registration form and $25 deposit to: Iowa Regular Baptist Camp, PO Box 80, Ventura, IA 50482. Jr. Boys (Entering 4-6th Grade) June 15-20 Jr. High (Entering 7-9th Grade) July 13-18 Jr. Girls (Entering 4-6th Grade) June 22-27 Sr. High (Entering 10-2020 Graduate) July 27- Aug 1
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Camper’s Name
Grade entering in the fall
ST Zip
Secondary Phone
M F Birth Date
Father’s Full Name
Mother’s Full Name
Mailing Address
City
Cell Phone
Parent’s Email:Camp Requested (Please check one):
Youth Camps Registration 2020Pre-registration deadline: May 15th!
Parents: Please completely fill out and sign (please print)
Home Church & Church’s City
Attending with Church & Church’s City (if different from home church)
Family Dr./Phone
Insurance
Policy#
Medications Taken Regularly (Must be in original container)
Do we have parent/guardian permission to give: Advil Yes No Tylenol Yes No
Current Infectious Diseases or Conditions
Allergic Reactions: Bee Stings Food Other
Date of Last Tetanus Shot Other medical concerns for your child
I hereby give permission for my child to attend IRBC, to participate in all activities, and for any picture/testimony of my child to be used in promotion of the camp. I understand that IRBC has a secondary accident insurance policy with a limit of $5,000 (illness is not covered). I hereby give consent for medical treatment deemed necessary for my child named above.
Signature of Parent or Guardian Date
In Case of Emergency, Contact Phone
Office Use Only: Postmarked: Amount Received $
Check No. Balance Due $
Send registrations in with your church if there is a group coming from your church. If registering individually, mail registration form and $25 deposit to:
Iowa Regular Baptist Camp, PO Box 80, Ventura, IA 50482.
Jr. Boys (Entering 4-6th Grade) June 15-20Jr. High (Entering 7-9th Grade) July 13-18
Jr. Girls (Entering 4-6th Grade) June 22-27Sr. High (Entering 10-2020 Graduate) July 27- Aug 1
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