Retreat Registration Form

Ponderosa Bible Camp Retreat Registration

Date of Weekend Retreat for which you wish to register: *
This camper is a boy or girl: *
Students Last Name: *
Students First Name: *
Students Date of Birth: *
Grade in School: *
Students mailing address: *
Students City: *
State:
Zip Code: *
Emergency Contact #1 *
Emergency Contact #2
Today's Date *
School student attends:
Name of Church (if attending):
Roommate Preference (1 friend attending/must also request you)
Health Information of student:
Please list any health problems, allergies, or special needs of this student:
Please list any activities that should be restricted while at camp:
Please check any that apply to this student:	ADD/ADHD Asthma Depression Diabetes or Low Sugar Ears Eating Disorder Heart Hepatitis HIV Positive Seizures Other
I have checked my student for Head Lice and I understand that during check-in my student will be checked again for Head Lice. I understand that my child will NOT be allowed to stay at camp if any lice or eggs (dead or alive) are found on this student: *
Date of last Tetanus or DPT shot:
Date of last doctor exam:
Family Doctor/Pediatrician: *
Doctors Phone number: *
Name of Campers Insurance Coverage: *
Campers Insurance Policy #: *
Campers Insurance Group #: *
Campers weight: *
Campers height: *
This health history is correct as far as I know, and the person described has permission to engage in camp activities. I understand that neither the camp nor the camps insurance company will be responsible for medical treatment or liability for any pre-existing conditions my child had before arriving at camp. I hereby give permission to the first aid personnel selected by the camp to provide standard first-aid care and administer over-the-counter medications if needed in the event I cannot be reached during an emergency. If I cannot be reached during an emergency I hereby give permission to the physician selected by the camp to order x-rays, routine tests, hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child named above. I hereby give my permission to use pictures or videos of my child taken during camp in any promotional material in which my child may appear. *
E-mail Address: *
Full Name of Parent completing this form: *
For proper identification please give the last 4 digits of the social security number of the parent completing this form: *
Phone number where parent can be reached in case we have any questions about this registration: *
Please list any prescription medication this camper will be bringing to camp: (Please have these medications ready to give to the nurse during check-in):
Does this camper participate in Dekalb County Released Time? If so, which school?
Is this camper enrolled in The Mailbox Club Bible Lessons? If not, would you like to start earning a discount for summer camp 2012?


* Required

Ponderosa Student Ministries is a 501(c)3 Non-Profit Organization Ponderosa Student Ministries is an affiliate of Children's Bible Ministries with locations from South FL to VA Click here to subscribe to our Email list if you want to stay informed about this ministry and camp info! We promise your email address will not be sold or shared with anyone else.