Pre-registration deadline: May 15th!...If registering individually, mail registration form and $25...

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