Online Registration

Instructions: Fill out this form completely and click the "send" link at the bottom of the electronic form. You will then need to print out the Payment Form at the bottom of the form and submit it with appropriate signatures and the initial payment for the camper. Mail the completed Payment Form to Willowbrook Bible Camp at the address listed on the form.

Camper Name

Your Email

Age:

Gender

Grade (Completed in June)

Parent or Guardian Name

Home Phone

Relationship to Camper

If Other:

Address

City

State

Zip

Work Phone:

Mobile Phone

Pager

Email: Parent

Email: Camper

If above are not available in an emergency, notify:

Relationship to Camper

Home Phone

Work Phone

Mobile Phone

Please indicate the camp you plan to attend:

Camp

Camper Status

Age Clarification: The beginning age for each camp must be reached by July 1. If age changes from one camp to the next during July, camper can attend either camp or both.

The undersigned acknowledges and agrees that Willowbrook Bible Camp ("WBC") reserves the right to use any photographs of the camper, staff, or visitors. The undersigned also acknowledges and agrees that the camper will be involved in many activities (e.g., swimming, wall climbing, ball sports, etc.) that may be potentially dangerous and that no amount of care, caution, instruction, or expertise can eliminate all such danger.

By your signature below and the camper''s participation in any WBC activity, you acknowledge and assume the risk, and hereby release and discharge WBC, its directors, employees, staff, and agents from liability for any injuries to property or person arising from such activities.

You covenant with WBC that you will never, individually or as legal guardians of participating individuals, institute any action at law or equity for any injuries to person or property caused by or arising out of activities sponsored by or on behalf of WBC.

You further agree to indemnify and hold harmless WBC, its directors, employees, staff, and agents against any and all costs, damages, and expenses (including court costs and attorney fees) incurred as a result of any legal claim or action instituted by you or the Camper.

Signature of Camper (Name)

Date

Color of eyes of camper (confirming electronic signature)

Parent or Guardian Signature

Date

Color of eyes of Parent/Guardian (confirming electronic signature)

The following information is used to (a) inform kitchen staff about dietary needs; (b) educate cabin leaders and directing staff about camper needs; and (c) provide healthcare staff with background about your child.

Health History

Date of last health exam

Name of Physician

City

Phone Number

Is camper under the care of a physician for a medical or psychological concern?

If yes, please explain

Allergies:

Is your camper free of known allergies?

This camper is allergic to the following food(s):

Does this allergy cause anaphylaxis?

Describe the reaction if the food is eaten and what is done to manage it.

This camper is allergic to the following medication(s):

Does this allergy cause anaphylaxis?

Describe the reaction to this medication if taken and what is done to manage it.

This camper is allergic to the following substance(s):

Does this allergy cause anaphylaxis?

Describe the reaction and what is done to manage it.

Check all that apply:

Health concerns: (Check all that apply)

This camper has no health concerns and is capable of full participation in this program.
Asthma
Migraines
Diabetes
Frequent ear infections
Bed-wetting
Heart defects/disease
Seizures
Bleeding disorder

Other Health Concerns (Please explain)

Please explain and provide information including treatment for each item checked:

Medication: Provide complete information.

All medication including vitamins and herbs MUST be sent in the original container with original label or it will not be given.

DO NOT send non-prescription medication unless taken on a daily basis, because it is provided by the camp. Please be prepared to turn in all medication including vitamins and herbs to the nurse upon arrival.

What have we forgotten to ask?

Provide additional information about your child''s health which may have been neglected on this form. We are particularly interested in information which has an impact upon your child''s ability to fully participate in the camp program. Supply additional information if needed.

Health Insurance Information:

This camper has health insurance?

Please copy both sides of the appropriate health insurance card so that addresses and phone numbers are available, and mail the copies with your downpayment. Please make sure the camper''s name appears on the copies.

Parents/Guardians are financially responsible for health care given by an out-of-camp provider. Please list below the parent/guardian who will pay for this camper''s health care bills should it be necessary to take your child to an out-of-camp provider. Do not list insurance information here.

Name of Parent/Guardian responsible for health care bills

Address

Phone Numbers

Parent/Guardian Authorization for Health Care:

This health history is correct, and the person described has permission to participate in all camp activities except as noted by me. I give permission to the camp health care staff to administer the medication as listed on this form, and to perform treatment for and administer medication for minor injuries and illnesses.

Furthermore, I give permission to the Willowbrook Bible Camp staff to transport my child to or from a health care provider, and I give permission to the physician selected by the camp to order X-rays, routine tests and treatment for the health of my child.

If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child. An electronic copy of the contents of this form shall be accepted as an original. Willowbrook Bible Camp has permission to obtain a copy of the health record of my child from the providers they access to treat my child.

I understand that health information about my child will be shared with other camp staff on a "need to know" basis.

Electronic signature of Parent/Guardian (Name)

Date

Color of eyes of Parent/Guardian (to confirm electronic signature)

For questions about this health form or to speak with a member of our Directing Staff, please call the camp at 515-262-5026.

NOTE: If you would like to donate money to the scholarship fund, which assists campers who need financial help, please indicate the amount below and include it with your check.

Scholarship Donation Amount

DISCOUNTS:

Early Bird (full payment before June 1) - minus $10

Bring a Friend (a first-time camper who is not a sibling) - minus $10

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