First Name: Last Name: Age: Birthdate (mm/dd/yy): Sex: MF Entering Grade: Home Phone: Home Address: City: State: Zip: E-mail address: Parent/Guardian: Work #: Home Church: Pastor: Emergency Contact: Phone: Insurance Co: ID #: Group # Child's physician: Phone #: Health problems: Special Diet: Allergies (food, medication, etc.): Brief Medical History: Last tetanus (mm/dd/yy): Medications/Dose/Route/Frequency *Medication must be sent in original container with original pharmacy instructions or CWB staff or programming group will not be responsible for the administration of the medication. Describe any other problems or special circumstances regarding your child, i.e. bedwetting, depression, attention deficit disorder, fears, death in the family, etc.: List any special instructions: Notice of Permission: In case of emergency, I hereby give permission to the physician selected by the camp nurse and/or director to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery, as he/she deems necessary for my son or daughter. Please Check Box Below That Applies to You: (One form per camper) Introductory (going into 2nd & 3rd grade) July 18-20 Cost: 2/$135.00 Primary (going into 3rd & 4th grade) July 14-17 Cost: $115.00 Junior (going into 5th & 6th grade) July 21-25 Cost: $140.00 JR High (going into 7th & 8th grade) July 7-11 Cost: $170.00 SR High (going into 9th-12th grade) July 28- August 1 Cost: $175.00 T-shirt size: Camper's Expectations While at this camp I intend to be a positive influence on others and the surroundings. Therefore I affirm and will follow these six expectations: I expect to participate in every aspect of this camp to the level of my ability, attending and cooperating in all portions of the program. I expect to conduct myself in a responsible manner at the campsite. I expect my privacy and personhood will be respected by others at the camp and will give the same respect to them. I expect this camp to enhance my physical, social, mental and spiritual well being and will therefore not use or possess drugs, alcohol or tobacco products at this camp. I expect to make a positive impact at this camp and will therefore dress appropriately at all activities. If I am unsure about the meaning of "dress appropriately" I will ask my youth director immediately. I expect God to touch my life through this camp. Camper's Signature: Date: Parent/Guardian's Signature: Date: I approve my child attending this camp and understand that camp activities may include off-site activities approved by the camp director and properly chaperoned. Planners of this camp believe that you are of high caliber and will have no difficulty with these expectations. However, when necessary, parents will be notified and campers will be sent home at their own expense. We believe in you and do not anticipate any problems.