Warrensville Road Community Baptist Church

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					    Camp Genesis is designed to enrich your child’s mind, body and spirit.
Welcome to the 5th Annual Summer CAMP GENESIS! Registration for camp begins
February 1, 2011. Camp runs June 6 to August 5, 2011.

Registration forms must be turned in to the enrollment clerk, Sis Frankie. She may be
contacted at 216-663-6691, leave a message and your call will be returned within 24 hours.
PLEASE DO NOT contact or give registration forms to the church clerk!!!

Enrollment packets are available from the website at www.campgenesiskids.com. You may
also get an enrollment packet from Sis. Frankie or the camp director, Sis. Sharon.

REGISTRATION IS FIRST COME, FIRST SERVE! We anticipate full enrollment as parents are
calling already!!!!! We are at 2/3 of our capacity.

Warrensville Road Community Baptist Church-5045 Warrensville Center Rd, Maple Heights
 (Registration times will be posted weekly on website and recorded message on 216-663-6691)
Camp hours: Doors open at 7:30 to 3:00 p.m. (breakfast @ 9:00 & lunch @12:00 Noon)

The following is also due at the time you turn in your camp application:
$135 activity fee – current church members
$195 activity fee – non church members
$ 10 t-shirt fee (different shirt from last year) purchase of a t-shirt is MANDATORY.

This is a one- time fee for the entire 9 weeks and must be paid in full PRIOR to the start of
are no refunds!!!! ( Extreme circumstances i.e. medical or death in family MAY BE given
consideration at the discretion of the camp director & staff. This does not guarantee REFUND. )


We are non-profit operating with a volunteer staff, however, NEW THIS YEAR will be several
non volunteer adult staff members who will assist with supervision of the campers and youth
workers. The supply/activity fee covers reading/math materials, spiritual lessons, educational
supplies, games, crafts, playground equipment, snacks, treats, stipends for our teen volunteers
and compensation to adult staff.

Enrollment is nearly full!!! We will only hold spots paid in full!! We look forward to a wonderful,
spirit filled summer with your child at CAMP GENESIS 2011.

Sis. Sharon Steward,
Camp Genesis Director
                            “CAMP GENESIS 2011”
                       Site I-Warrensville Road Community Baptist Church

Child’s Name__________________________________________ Age ___________________

Date of Birth _________________________ Home Phone Number _____________________

Address ________________________________City/State/Zip__________________________

School Attended_______________________            Grade in Fall 2011_____________________

Emergency Contact Information

Parent/Guardian Name:_________________________________________________________

Home Phone: ______________ Cell Phone _______________ Work Phone _______________

Email Address (please print clearly)________________________________________________

Emergency Contacts:
Name: ___________________________ Relationship to child: __________________________

Home Phone: ______________ Cell Phone _______________ Work Phone _______________

Name: ___________________________ Relationship to child: __________________________

Home Phone: ______________ Cell Phone _______________ Work Phone _______________

Medical Information
Does your child have any medical problem(s) that camp staff should be aware of? Yes No
Please explain any “yes” answers below: (such as asthma, diabetes, food or other allergies, etc.)

Does your child take any pills, medicines, injections, inhalers, either on a part-time or regular
basis? Yes No Please explain any “yes” answers below.


Is your child diagnosed with any of the following: (ADHD, ED, DH, MH, RAD, PTSD, other If so
please explain how this may affect them at camp )

Child’s hobbies and interests:
Has your child ever received Special Education Services? Yes , No If yes, please explain:

Things your child may need help with:

Describe your child’s personality:



Physician’s Name________________________________ Phone_________________________

Dentist’s Name__________________________________ Phone_________________________

Preferred Hospital__________________________ Address _____________________________


In case of accident or serious illness, I request Camp Genesis Staff to contact me. If staff is unable to reach
me at the numbers listed above, I hereby authorize the staff to call the physician(s) listed above and to
follow his/her instructions. If it is impossible to contact this physician, the staff is hereby authorized to take
whatever action is deemed necessary in their judgment, for the health of said child.

I will not hold Camp Genesis financially responsible for emergency care and/or transportation of said child.

_____________________________________________ _______________________
         Signature of Parent/Guardian                 Date
PERMISSION SLIP (please print clearly- form needed for each child)

I give permission for my child____________________________________

to leave the camp grounds with adult staff for walks in the neighborhood.

Parent’s Signature ________________________ Date ________________

I give permission for my child ____________________________________

to be photographed, videotaped or recorded and used by the Camp Genesis staff for
publicity purposes i.e Camp Genesis website, brochures, etc.

Parent’s Signature_______________________ Date _________________

Spiritual Background

Does your child attend church ___________

If so what church?______________________________________________

Has your child been baptized?___________ When?__________________

Does your child participate in any ministries-choir, usher? If so, which

How would you like to see your child grow spiritually?________________

                                   DISCLAIMER NOTICE
    (Warrensville Road Community Based Center of Life/Warrensville Road Community Baptist Church)

Please read the following agreement before signing. Although camp participation is encouraged,
it is encouraged only if health & safety are considered.

Name of Camper ____________________________________ (PLEASE PRINT)

*I have seen the Warrensville Road Community Baptist Church grounds and hereby give
permission for my child to use all the facilities including playground equipment and community
(Stafford Park) athletic grounds. I hereby find them safe and suitable for my child. ______(initial)

*I understand a risk of participation in any sports, including Camp Genesis, is the risk of the injury,
including but not limited to serious permanent injury. To minimize the risk of injury, I agree to tell
my child to obey all safety rules and to report fully any problems related to his/her physical
condition to summer camp staff as soon as the problem begins. ________(initial)

*I certify that my child is medically cleared to participate in physical sports, is fully immunized and
physically and mentally able to participate in all physical activities of the program. ______(initial)

*I certify that my child’s medical records are complete, on file as required by their school district. I
certify that my child is covered by a health insurance policy and I agree to be responsible for any
hospitalization or other required treatment. ______(initial)

*I understand that my child will be transported to/from all field trips in privately owned vehicles or
church van and hereby release Warrensville Road Community Baptist Church and Warrensville
Road Community Based Center of Life, its’ directors, employees or volunteers of any and all
liability that may occur at the church, during any athletic activity, or during any optional field trip or

By signing below I certify the following:

_____that my child is not currently under the care of a physician for an injury, illness or mental
health condition that would prevent his/her safe participation in camp,
_____that my child is not currently being treated for or recovering from an injury that would prevent
his or her safe participation in the summer camp
_____ that my child has no history of fainting or other problems related to strenuous exercise
_____ that my child is in good health and there is no reason he or she cannot safely participate in
strenuous physical activity.
_____that this disclaimer form has been reviewed, explained and I was given an opportunity for
clarification by Camp Genesis staff.

Parent/Guardian Signature ____________________________________ Date ___________

Staff reviewed/explained form___________________________________ Date ___________

I give permission for the people listed below to pick up my child _______________________
from Camp Genesis.

NAME                                      RELATIONSHIP             TELEPHONE

_______________________________           __________________       _______________

_______________________________           __________________       _______________

_______________________________           __________________       _______________

_______________________________           __________________       _______________

_______________________________           __________________       _______________

_______________________________           __________________       _______________

Parent/Guardian’s Signature_____________________________        Date_________________

CHILD’S NAME___________________________ Amt. Enclosed __________             Check____/Cash_____

  Children S, M, L - $10.00 Adults S, M, L, XL, 2XL- $10.00   Adults 2XL-3XL - $12.00

   Quantity                                 Quantity

   ______ Child Small                        ______ Adult Small

   ______ Child Medium                      ______ Adult Medium

   ______ Child Large                        ______ Adult Large

                                             ______ Adult X-Large

                                    Total #shirts_____X $10.00=_______

                                            ______ Adult 2X-3X-Large

                            Total #shirts   ______X$12.00=______
                             Camper Code of Conduct
The Code of Conduct is to be signed by the camper and parent(s). Our goal is to ensure
the safety and enjoyment of each camper. Campers are expected to behave
appropriately. Parents please review the Code of Conduct with your child BEFORE camp
begins so they fully understand the expectations.

CHILD’S NAME (PLEASE PRINT) ___________________________________

As a camper, I will:

*Show respect to staff, visitors, and other campers.

* Cooperate fully with staff’ instructions.

* Follow the rules of the camp and be responsible for knowing the rules.

*Respect the rights and opinions of others and show courtesy.

*Not use cursing, teasing, name calling, obscene gestures, yelling with my peers or staff.

*Will not cause injury, bodily harm, rough play to other campers or staff. This includes
pushing, kicking, hitting or fighting which are not acceptable and will not be tolerated.

*Respect the property of other campers.

*Use program equipment properly and will not intentionally damage equipment. This
includes breaking playground toys and board games. I understand that if I do, my parents
may be requested to pay for the damages.

*Take responsibility for my actions and understand that irresponsible behavior will result
in disciplinary action.

Camper’s Signature _____________________________            Date_____________________

Parent’s Signature _______________________________________

Parent’s Signature _______________________________________

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