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					                                                          BRING TO CAMP FOR REGISTRATION
               WINTER CAMP                                I submit this application to Carolina Bible Camp & Re-
                                                                                                                                 Date of Last Tetanus Shot: ________________________
                  2012                                    treat Center Inc., for admission in the 2012 winter session,
                                                                                                                                 Allergies:       [ ] Bee Stings
                                                          and I promise to abide by the rules and policies of the
              CAMPER/STAFF                                camp.
                                                                                                                                                  [ ] Penicillin
                                                                                                                                                  [ ] Other (Give Details):
               APPLICATION                                                                                                       Chronic Illnesses:
                                                          Signature: ______________________________
                                                          Note: Workers must be approved by the director.
  January 13th, 2012 6:00PM                                             Don Rhodes: 336-751-5874

             Thru                                         Check             Type        Ages                Classification       Medication Camper is on (list type and dosage).

January 16th, 2012 12:00 Noon                                                C        13 to 21             Camper - Fee $60

                                                                             W        16 to 21             Worker - Fee $0

   MAIL THIS APPLICATION TO:                                                 D        13 to 21        Dependant - Fee $20        Special dietetic requirements:
          DON RHODES                                                         V     22 and Above        Volunteer—Fee $0
     1892 Jericho Church Road                                        If Volunteering, State Type of work below                   Insurance Company and Policy Number:
       Mocksville, NC 27028
                                                                                                                                 Other Comments:
         Medication should be labeled with the
camper’s name and recommended dosage. All
medication should then be placed in a re-sealable
plastic bag with the camper’s name written on the        Name:                                                                               In consideration of the acceptance of the named applicant,
                                                                  (First)          (Middle)       (Last)           (Preferred)
outside. Any notes to the camp Nurse should be                                                                                   we, the undersigned parent, parents, or guardian, as the case may be,
inside the bag for their review. This bag should be                                                                              covenant and agree with Carolina Bible Camp and Retreat Center, Inc.
                                                         Sex:     Male   [ ] Date of Birth                     /     /           that we will at all times hereafter indemnify, keep indemnified, and
brought to registration. Campers should not retain                Female [ ]                           (month/day/year)          save harmless the said Carolina Bible Camp and Retreat Center, Inc.
their own medication. This is for the safety of the                                                                              from all actions, proceedings, claims, demands, cost damages, and
other campers.                                           Address:                                                                expenses, which may be brought against or claimed from Carolina
                                                         Street: __________________________________________                      Bible Camp and Retreat Center, Inc., or which I may pay, sustain, or
                                                                                                                                 incur as a result of illness, accident, or misadventure to the named
         Campers may need money for two nights of                                                                                applicant, during the period that said applicant is a participant at
the canteen. Usually movies are shown on Saturday        City: __________________ State: ______ Zip: _________                   Carolina Bible Camp and Retreat Center, Inc.
and Sunday evenings. Campers will have the                                                                                                   The person listed above has permission to engage in all
                                                         Telephone: (______)_____________________________                        prescribed camp activities, except as noted. He/she is believed to be in
opportunity to purchase drinks and snacks from the                                                                               satisfactory health and free from communicable disease.
canteen during the movies.                                                                                                                   In the event I cannot be reached in an emergency, I hereby
                                                         Emergency Tel: (______)__________________________
                                                                                                                                 give permission to the physician selected by the camp director to
          Lost articles can not be mailed or saved.                                                                              hospitalize, secure proper treatment for, and to order injection,
                                                                                                                                 anesthesia or surgery for camper.
Each year, hundreds of items are left behind. The                                                                                            It is agreed that the camp assumes no responsibility for
cost to store and mail these items are such that CBC     E-mail:________________________________________                         personal property and is released from liability in connection with
can not provide these services. Please check your                                                                                medical ministrations except covered by camper insurance. Camper
camper’s luggage and the lost-and-found location         Home Congregation:______________________________                        insurance does not cover pre-existing conditions or illness.
before leaving the campus.                                Parent: Do you wish to be contacted if camper wishes to be                         PARENTAL AUTHORIZATION
                                                          baptized? Yes [ ] No [ ] Already Baptized [ ]
Visitors should check in and out with the director. If                                                                           Witness our hand(s) this ___________________________
staying for a meal, donations should be given to the                                                                             _______________________________________________________
director to cover the cost of the meal.                   Check Number ____________ Amount for this camper $ _______
                                                                                                                                                      (Parent or Guardian Name—Print)

                                                                                                                                                        (Parent or Guardian Signature)

Check in between 5:30pm and 8:30pm
on Friday. Please call the camp to let us know if you will
                                                               “IS THY                                                                          WINTER CAMP
be arriving late.                                                                                                                               CAMPER/STAFF
                                                             HEART RIGHT
Campers are to be picked up by 12:00 Noon on Monday.

                                                                                                                                                           Dedicated to

                                                             WITH GOD?”                                                                          Bible Teaching
                                                                                                                                        Wholesome Recreation
                                                                         WINTER ENCAMPMENT                                                                  Since 1956
                                                                       Don Rhodes will serve as Camp Director for the
                                                             winter 2012 session. Serving with him will be several staff
                                                             members that will be working as teachers, speakers, counsel-
                                                                                                                                     January 13, 14, 15 & 16
                                                             ors and kitchen staff.
                                                                       Bible teaching and religious services are the center                 Christian Youth Camp
WHAT TO BRING:                                               of Carolina Bible Camp. Our goal is to teach and demonstrate          Carolina Bible Camp and Retreat Center
                                                             Christian principles and living. There will be a worship ser-
                                                             vice on Sunday morning. Campers will have devotional and
          Bring a Bible, notebook and pencil, a              worship opportunities during the encampment.                        CBC is a non-denominational Christian camp
sleeping bag (or sheets and blanket), pillow, towels,                  Recreation is provided for each camper in the after-    dedicated to the youth of America and is operated
jacket, sneakers, toilet articles (soap, toothbrush,         noon and each camper must participate in some kind of ser-                   as a non-profit organization.
comb, etc.), flashlight, musical instruments (if             vice project around the camp facility.
desired), sports equipment and plenty of warm                          Care should be taken with camp property at all           (Campers are accepted without regard to race, creed, or nationality)
clothing. Make sure all items are carefully identified.      times by staff and campers alike. Campers and staff are liable
Bring money for the canteen.                                 for any property damage inflicted by them as a result of inten-         (Do Not Mail To This Address)
                                                             tional vandalism, negligence, or horseplay.
WHAT NOT TO BRING:                                                     Modesty and good behavior are a basic in a Chris-           Camp Address & Telephone Number
         Do not bring food! Any snack food brought           tian camp. Camper and Staff alike are expected to live in ac-                    CBC & Retreat Center, Inc.
to camp will be taken on Friday and returned to the          cordance to good Christian morals.                                                1988 Jericho Church Road
camper on Monday. Any food brought for medically-                                                                                                Mocksville, NC 27028
mandated special diets is to be kept in the kitchen,                                                                                         Phone Number 336-492-7802
                                                                 Directions to CBC and Retreat Center
under oversight of the Kitchen Director.                                                                                            
         Do not bring radios/2-                                  Take I-40 to US Hwy. 64, (Exit 168). Exit South
way radios/TVs/iPods/cell                                       on Hwy. 64 approximately 1/2 mile. Turn right on
phones.                                                                                                                            MAIL THIS APPLICATION TO:
                                                                   Greenhill Rd. Proceed to stop sign at Davie
         Do not bring cigarettes,                                Academy Rd. Turn left and proceed 1/2 mile to                            DON RHODES
matches, fireworks, knives, or                                    Camp entrance on the left (just beyond Jericho                     1892 Jericho Church Road
pets of any kind.                                                    Road Church of Christ meeting house).
                                                                                                                                       Mocksville, NC 27028

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