Winter Retreats 2017 Winter Retreats 2017
Camper Registration & Medical Release Form
Camper Registration & Medical Release Form
Winter Retreats 2017
Winter Retreats 2017
Meltdown #1 - Jan. 13-15
Jr. FreezeOut #1 - Jan. 20-21
Meltdown #1 - Jan. 13-15
Jr. FreezeOut #1 - Jan. 20-21
Meltdown #2 - Jan. 27-28
Jr. FreezeOut #2 - Feb. 3-4
Meltdown #2 - Jan. 27-28
Jr. FreezeOut #2 - Feb. 3-4
Meltdown #3 - Feb. 10-12
Meltdown #3 - Feb. 10-12
Camper Name:
Camper Name:
Address:
Address:
City, State, Zip:
City, State, Zip:
Home Phone:
Home Phone:
Email:
Email:
Church & City:
Church & City:
Parent(s) Full Name(s):
Parent(s) Full Name(s):
Cell Phone(s):
Cell Phone(s):
Family Doctor:
Family Doctor:
Doctor’s Phone:
Doctor’s Phone:
Insurance & Policy Number:
Insurance & Policy Number:
Medications Taken:
Medications Taken:
Allergies:
Allergies:
Other Medical Concerns:
Other Medical Concerns:
Does IRBC have permission to give: Tylenol: Yes/No
Advil: Yes/No
Does IRBC have permission to give: Tylenol: Yes/No
Advil: Yes/No
In case of medical emergency, I give consent for emergency treatment by authorized personnel for my child named above. The camp carries secondary insurance, which means all claims must be submitted to the parents’ insurance first. I understand that sickness is not covered by insurance. I hereby give permission for my child to attend this retreat.
In case of medical emergency, I give consent for emergency treatment by authorized personnel for my child named above. The camp carries secondary insurance, which means all claims must be submitted to the parents’ insurance first. I understand that sickness is not covered by insurance. I hereby give permission for my child to attend this retreat.
Parent/Guardian Signature:
Parent/Guardian Signature:
Date:
Date:
Jr. FreezeOut #1 January 20-21
Jr. FreezeOut #2 February 3-4
Jr. FreezeOut #1 January 20-21
Jr. FreezeOut #2 February 3-4
Meltdown #1
Meltdown #1
January 13-15
January 13-15
Meltdown #2
Meltdown #2
January 27-28
January 27-28
Meltdown #3
Meltdown #3
February 10-12
February 10-12
Cost: $45 Camper & $25 Counselor Registration: Friday 6:15-7:15 p.m. Retreat Ends: Saturday 4:15 p.m.
Cost: $45 Camper & $25 Counselor Registration: Friday 6:15-7:15 p.m. Retreat Ends: Saturday 4:15 p.m.
Cost: $60 Camper & $35 Counselor Registration: Friday 7:00-8:00 p.m. Retreat Ends: Sunday 11:30 a.m.
Cost: $60 Camper & $35 Counselor Registration: Friday 7:00-8:00 p.m. Retreat Ends: Sunday 11:30 a.m.
Find forms & info at:
Find forms & info at:
Camper Registration & Medical Release Form
Winter Retreats 2017
Winter Retreats 2017
Meltdown #1 - Jan. 13-15
Jr. FreezeOut #1 - Jan. 20-21
Meltdown #1 - Jan. 13-15
Jr. FreezeOut #1 - Jan. 20-21
Meltdown #2 - Jan. 27-28
Jr. FreezeOut #2 - Feb. 3-4
Meltdown #2 - Jan. 27-28
Jr. FreezeOut #2 - Feb. 3-4
Meltdown #3 - Feb. 10-12
Meltdown #3 - Feb. 10-12
Camper Name:
Camper Name:
Address:
Address:
City, State, Zip:
City, State, Zip:
Home Phone:
Home Phone:
Email:
Email:
Church & City:
Church & City:
Parent(s) Full Name(s):
Parent(s) Full Name(s):
Cell Phone(s):
Cell Phone(s):
Family Doctor:
Family Doctor:
Doctor’s Phone:
Doctor’s Phone:
Insurance & Policy Number:
Insurance & Policy Number:
Medications Taken:
Medications Taken:
Allergies:
Allergies:
Other Medical Concerns:
Other Medical Concerns:
Does IRBC have permission to give: Tylenol: Yes/No
Advil: Yes/No
Does IRBC have permission to give: Tylenol: Yes/No
Advil: Yes/No
In case of medical emergency, I give consent for emergency treatment by authorized personnel for my child named above. The camp carries secondary insurance, which means all claims must be submitted to the parents’ insurance first. I understand that sickness is not covered by insurance. I hereby give permission for my child to attend this retreat.
In case of medical emergency, I give consent for emergency treatment by authorized personnel for my child named above. The camp carries secondary insurance, which means all claims must be submitted to the parents’ insurance first. I understand that sickness is not covered by insurance. I hereby give permission for my child to attend this retreat.
Parent/Guardian Signature:
Parent/Guardian Signature:
Date:
Date:
Jr. FreezeOut #1 January 20-21
Jr. FreezeOut #2 February 3-4
Jr. FreezeOut #1 January 20-21
Jr. FreezeOut #2 February 3-4
Meltdown #1
Meltdown #1
January 13-15
January 13-15
Meltdown #2
Meltdown #2
January 27-28
January 27-28
Meltdown #3
Meltdown #3
February 10-12
February 10-12
Cost: $45 Camper & $25 Counselor Registration: Friday 6:15-7:15 p.m. Retreat Ends: Saturday 4:15 p.m.
Cost: $45 Camper & $25 Counselor Registration: Friday 6:15-7:15 p.m. Retreat Ends: Saturday 4:15 p.m.
Cost: $60 Camper & $35 Counselor Registration: Friday 7:00-8:00 p.m. Retreat Ends: Sunday 11:30 a.m.
Cost: $60 Camper & $35 Counselor Registration: Friday 7:00-8:00 p.m. Retreat Ends: Sunday 11:30 a.m.
Find forms & info at:
Find forms & info at:
