Camper Registration Form

First Name

Last Name

Age

Birth Date

Grade Completed

3
4
5
6
7
8

Gender

Male
Female

Church Attending

Home Address

City

State

Zip Code

Primary Phone Number

Work or Secondary Phone Number

E-mail Address

Parent / Guardian Name

Week Attending Camp

July 21-25 (completed grades 3-6) (Mon-Fri)
July 28 - Aug 1 (completed grades 5-8) (Mon-Fri)

Registration Fee (Full payment for a Week is $170 - $180 after July 11th. Pay minimum of $40 to hold your spot.

Canteen ($12 recommended)

Offering for Missions project (optional)

T-shirt (optional) $15

Yes
No

T-Shirt size (If purhased)

YS
YM
YL
AS
AM
AL
XL
XXL

To guarantee T-shirt, registration must be in by July 12th.

Donation (optional)

Total Payment Amount

Registration is not complete until you pay the minimum registration fee of $40 by either sending a check made out to Solid Rock Bible Camp and sent to; Solid Rock Bible Camp, 320 NE 20 Ave. Great Bend, KS 67530. Or, clicking on the "Pay Now" button on the bottom of this form. (Complete registration form first and click on the "submit" button, then a link will bring you back to this page with a blank form so you can click on the "Pay Now" button to pay your registration fee)

$170 for each week - $180 after July 11th.

Medical Information

In case of emergency, notify

Relationship to camper

Primary Phone Number

Work / Secondary Phone Number

Parent / Guardian Health Insurance Company

Employee Number

Policy Number

Is the camper able to participate in all activities?

Yes
No

If "No", please explain.

Health History

Is camper able to sleep on a top bunk?

Yes
No

Does camper have a current bedwetting problem?

Yes
No

Are all shots current?

Yes
No

DPT Series - Date

Did the camper have a surgery within the last year?

Yes
No

If "Yes", please explain.

Does camper have Epilepsy / Convulsions?

Yes
No

Does camper have Diabetes?

Yes
No

Does camper have digestive problems?

Yes
No

Does camper have Asthma/ Hay Fever?

Yes
No

Does camper have ear trouble?

Yes
No

Does camper have heart trouble?

Yes
No

Is camper able to take Tylenol?

Yes
No

Is camper able to take Ibuprofen?

Yes
No

Is camper able to take Benadryl?

Yes
No

Please list any allergies the camper has.

Does the camper take any medications?

Yes
No

If "Yes", please list name of medication, dosage / # of pills, and time given: breakfast, lunch, supper, or evening snack time.

Note: Medications brought by campers must be placed in a zip lock bag and clearly marked with camper's name and instructions. All medications must be turned in to the camp nurse.

I hereby request that in the event of an emergency, my child be taken to the nearest doctor or hospital for treatment and I be notified as soon as possible. I understand that I will be responsible for any medical expenses not covered by my insurance or camp insurance.

Yes
No

Camper Agreement

I understand that every effort will be made to protect and safeguard all campers. I agree not to hold SOLID ROCK BIBLE CAMP liable for any illness or mishap from any cause whatsoever which may be sustained. I also give the camp full authority in dealing with problems of discipline. I agree that any camper disregarding camp rules is subject to being sent home with no refund of camp fees. Likewise any camper who willfully destroys or defaces property will be held responsible and charged accordingly.

Yes
No

As a camper at SOLID ROCK BIBLE CAMP I promise to obey the rules and fully participate in the camp program.

Yes
No

Photo Release

I give permission to use pictures that include my child in the promotion of SOLID ROCK BIBLE CAMP and INFAITH.

Yes
No

If possible, the camper would like to be in the same dorm with:

Before submitting this form, please make sure that you check the "I'm not a robot" box and verify it.