Camper's Full Name (required)
Parent(s)/Guardian(s) Full Name (required)
Parent(s)/Guardian(s) Email (required)
Home Address (required)
Zip Code (required)
Home Phone Number With Area Code (required)
Alternate Phone With Area Code
Emergency Contact (Other than parent)(required)
Emergency Contact Phone with area code (required)
Health Insurance Company
Name of Primary Care Clinic
Has camper had problems with the following?
Recent SurgeryAsthmaPenicillinADD/ADHDBed Wetting
Insect StingsChicken PoxConvulsionsDiabetesEar Trouble
EmotionalEpilepsyHeart TroubleSkin ProblemsSeizures
If checked list date(s) here (Ex. Recent Surgery - 6/14/2014)
Vaccine Year of basic immunization
Year of booster
I understand that the above stated will be participating in programs sponsored Wood Lake Bible Camp. I also understand that the activities which participants will take part in may include, but are not limited to: motor vehicle transportation, hiking, canoeing, swimming, horseback riding, low ropes course events, high ropes course events and/or other camp related activities and games. While I expect proper supervision and safety precautions at all times, I understand that I assume the risk for any and all liability arising from such activities and do hereby agree to release and forever discharge Wood Lake Bible Camp, Inc. , its agents and employees, and its successors and assigns, any and all claims, demands, rights and causes of action whatsoever kind or nature, arising from and by reason of any occurrence, accident, event, or other happening arising out of the grant of and the use of such permission by me, hereby expressly releasing the aforesaid from any and all liability even at negligence of WLBC agents or employees.
I also give the camp full authority in dealing with problems of discipline. Any camper disregarding camp rules is subject to being sent home without refund. Campers who willfully destroy property will be held responsible and charged accordingly.
While at Wood Lake Bible Camp I authorize trained staff members to administer First Aid and/or CPR when necessary or other emergency medical care as appropriated by WLBC staff. I also authorize WLBC staff to transport the above stated participant to a medical facility for necessary emergency care.
In signing this form, I also am allowing comments, pictures, and/or video of the camper to be used for promotional and other uses relating to camp.
Camper Signature (YOUR NAME HERE and submission of this form constitutes your signature)
Parent or Guardian Signature (If camper is under 18)(YOUR NAME HERE and submission of this form constitutes your signature)