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									              2012 Grindstone Lake Bible Camp Registration Form
                                                                                                       IMMUNIZATIONS

Name________________________________________________ Birthdate ____/_____/_____
                                                                                                                               YES       NO                                            YES NO
Male / Female (circle one)      Grade completed__________ First time camper?____________               Diphtheria              ____     ____                  Polio                    ____ ____
                                                                                                       Measles                 ____     ____                  Mumps                    ____ ____
Parent/guardian______________________________ Parent email:________________________
                                                                                                       Whooping Cough          ____     ____                  Rubella                  ____ ____
Address_______________________________________________________________________                         Small pox               ____     ____                  Date of last tetanus:_____________
City____________________________________________                  State______Zip______________
Home phone (_____)___________________Work phone (_____)_________________________                       List any activity or dietary restrictions, eating disorders, health problems and/or medication your
Cell phone (_____)_____________________________                                                        child takes.______________________________________________________________________
                                                                                                       _______________________________________________________________________________

Please check the week you plan to attend according to the grade you have completed.                    CONTRACT /MEDICAL RELEASE:
                                                                                                        By signing this form, I give permission to GLBC to dispense medications (Rx and OTC
                                                              After 5/1             Early Bird Rate*   medication) to my child to manage illness and injury as deemed necessary by the Camp for the
           4th –6th Grade I          June 17—22                $165                    $160*          welfare of the camper. “In case of emergency, if I cannot be contacted, I hereby give permission
           1st-- 3rd Grade           June 30—July 4            $140                    $135*          to the physician selected by the Camp Director, to hospitalize, secure proper treatment for my
           7th – 9th Grade           July 8-13                 $165                    $160*          child, as named above. I understand that every effort will be made to protect and safeguard all
           3rd –5th Grade            July 15-19                $140                    $135*          campers. I understand a reasonable attempt will be made to contact me concerning any serious
                                                                                                       illness or injury involving my child. I agree not to hold GLBC liable for any illness or mishap
           K-2nd Day Camp            July16—20                 $20/day            (8am - 6pm)
                                                                                                       which may be sustained. I understand that GLBC is not responsible for any medical expenses
           10th - 12th Grade         July 22—27                $165                     $160          not covered by my insurance.
           6th—8th Grade             Aug.5—10                  $165                    $160*
           4th - 6th Grade II        Aug. 12—17                $165                    $160*          I also understand that any camper disregarding camp rules is subject to being sent home with no
                                                                                                        refund of camp fees. I understand that any camper who willfully destroys property will be held
*Early bird rate if registration is postmarked by May 1st. Pay in full by May 1st and receive a        responsible and charged accordingly.
FREE GLBC t-shirt!
                                                                                                       I give GLBC permission to use comments, photos, and video of the camper named above in its
**If attending Day Camp, which day(s) do you plan to attend? 25th 26th 27th 28th 29st                  promotional materials.

I would like to room with (if possible) _______________________________________________                Signature of parent/guardian___________________________________________________

Home church________________________________________City_______________________                         Signature of camper__________________________________________________________

I give my permission to these people to pick up my camper______________________________                Reg. Amount:                        _________ (Camp fee amount OR how much you are paying today)
                                                                                                       Donation:                           _________
_____________________________________________________________________________
                                                                                                       Canteen (max $35)                   _________
                                                                                                       GLBC t-shirt ($10)                  _________ (free if paid in full by May 1st !)
Health insurance company________________________________________________________                       Sweat shirt/Hoody ($25)             _________
Group #_______________________________________________________________________                         Archery Fee ($5 for week)           _________
                                                                                                       Pictures ($6 for 1; $10 for 2)      _________ (individual camper & cabin)
Physician’s name & phone no._____________________________________________________                      Rock Wall ($10)                     _________
                                                                                                       Craft upgrade ($3)                  _________ (this is a special craft project )
In case of emergency (if parent is unavailable) notify:__________________________________              Ded. Scholarship/Coupon             _________
Home phone (_____)____________________Work phone (____)________________________
                                                                                                       TOTAL ENCLOSED:                     _________

HEALTH INFORMATION                                                                                          Mail forms to: GLBC, 13222 Grindstone Lake Rd., Sandstone, MN 55072
                         YES       NO                                           YES NO                          Mail forms to: GLBC, 13222 Grindstone Lake Rd., Sandstone, MN 55027
Chicken pox              ____     ____                Heart trouble             ____ ____                                                           For office use only
Asthma                   ____     ____                Skin problem              ____ ____
Convulsions              ____     ____                Bed wetting               ____ ____                   Date Rec’d__________ Cash or Check#_________ Reg. Amt.________ Canteen______
Diabetes                 ____     ____                Allergic to:
Ear trouble              ____     ____                   Penicillin             ____    ____                T-Shirt________ Sw Shirt_______ Archery________ Photo_________ Wall_________
Emotional prob.          ____     ____                  Insect stings           ____    ____
                                                                                                          Craft _____ Donation__________ ACC _________ CSCH_________ SCH PD__________
Epilepsy                 ____     ____
                                                        Other___________________________                                                       TOTAL:_______________

								
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