Box 659, Riverton MB R0C 2R0 Registrar Ph. 1(888)802-7112
2015 Registration Form
CAMPER NAME
[Receive a $5.00 discount by registering online at www.beavercreekbiblecamp.com]
_____________________________________
BIRTHDAY (mm)
/ (dd) _____/ (yyyy) ______
GENDER _______ GRADE ENTERING IN SEPT. 2015 __________ EMAIL ______________________________________________________
ADDRESS
CITY
MB HEALTH #
PROV
(6 digit)PHIN#
PC______________________
(9 digit) FIRST TIME AT CAMP?____________
I WOULD LIKE TO BE IN A CABIN WITH ___________________________________________________________________________
(maximum 2 names, must be requested by both campers)
PARENT/GUARDIAN NAME _____________________________________________________
RELATION
MOTHER PRIMARY PHONE
WORK PHONE
CELL PHONE ______________________
FATHER PRIMARY PHONE
WORK PHONE
CELL PHONE_______________________
-EMERGENCY CONTACTSNAME
___
NAME_______________________________________
PH#(________ )________- __________ RELATION ____________________________
PH#(
)________-__________ RELATION____________________________
***TUCK IS INCLUDED IN PRICE - $20/REGISTRATION***
Summer Camp Weeks
Leadership Development Camp
Xtreme Paintball
Grades
Date
Price
11-12
July 4-11
$240.00
Ages 13-17
July 6-11
$335.00
Photography Camp
9-12
July 6-11
$220.00
The Edge Camp #1
6-8
July 13-18
$220.00
Adventure Camp
3-5
July 20-24
$210.00
Foundations #1
9-12
July 20-24
$215.00
The Edge Camp #2
5-7
July 27-Aug. 1
$220.00
Paintball Survivor Weekend
Ages 15-18
July 24-27
$200.00
Revolution Teen Camp
8-12
Aug. 3-8
$220.00
Foundations #2
9-12
Aug. 3-8
$220.00
$10 discount
by April 1st
Subtotal
Optional donation for
volunteer summer staff
honorarium
SUB TOTAL
You may pay a $35.00 deposit
now with difference due at
camp registration. Deposit is
NON REFUNDABLE!!
GRAND TOTAL
Method of payment
□ Cash □ Cheque □ Credit Card [NSF Cheques will result in a $25.00 fee to your Account]
Name on Card _________________________________________ Type of Card ______________________
Credit Card #
Expiry Date _________________
(Visa or Mastercard only)
Box 659, Riverton MB R0C 2R0 Registrar Ph. 1(888)802-7112
Activities (Please number the skills you would like to be in)[in order of preference.]
Paintball (Age 13+only)
Kayaking
Crafts
Outdoor Survival
Archery
Canoeing
Sports
Music & Band
Digital Photography
Drama
MapQuest
MEDICAL INFORMATION FORM
Family Doctor
Doctor’s Ph# (
Reason?
Has Camper had: Measles
)
-
Last Visit
Immunizations up-to-date?
Chicken Pox
Mumps
Rubella
Tetanus Shot
Other
Camper is subject to (check those that apply):
Asthma
Migraines
Diabetes
Stomach Aches
Arthritis
Heart Disease
Sinusitis
Tonsillitis
Frequent Colds
High Blood Pressure
Frequent Headaches
Epilepsy
Seizures
Earaches
Bedwetting
Other
What causes the above?
List any allergies (including food/meds)
Describe reaction and treatment
Does the camper wear a Medic Alert Bracelet?
Do they carry an Epipen?
Does the camper have any Physical
Behavioral
Emotional
Will your child need a one-on-one support worker at camp? Yes
(Please note, it is your responsibility to arrange for support workers.) SMD
concerns that may require special attention at camp? Please explain
No
CSS
If yes, which organization supplies your support worker
CFS
Other
MEDICATION POLICY For legal and safety reasons, ALL medications must be brought to camp in their original containers. All medications will be administered by the
camp Nurse. No medications other than Ventolin & Epipens are to be kept by campers or staff in their cabins or on their person. In instances of non-life threatening
illnesses, the camp Nurse will assess the camper and a supply of common Over-the-Counter (OTC) medications can be administered if deemed necessary. A list of
these medications is available upon request.
Are there any OTC medications you DO NOT WANT your child to receive?
Please describe current medications including dosage and times taken:
Waivers and Conditions of Beaver Creek Bible Camp Camper Enrollment
I certify that the camper is normal in condition (health and otherwise) and habits will be emendable to necessary discipline. The camp reserves the right to dismiss a
camper who is a hazard to safety and/or rights of others who appears to have rejected the reasonable controls of camp. I will also notify the camp if my child has
been exposed to any infectious disease within 3 weeks prior to camp.
I submit this application as the one having legal custody of the child. Conditions of custody if any will be fully communicated in writing to the camp including a copy of
any court orders dealing with visitation rights.
While all reasonable precaution is taken for the safety and good health of campers, I release Beaver Creek Bible Camp, its directors and staff members from any and
all liability in the event of an illness, accident, or misfortune that may occur to the applicant camper. Each camper must be covered by provincial health or equivalent
medical insurance.
I as the parent or guardian give permission and authorization to the BCBC camp director or his designate to arrange for any special services or other requirements
necessary for the campers welfare and good health including but not limited to medical advice, equipment, injections, anesthesia and surgery. In such situations the
camp will make attempt to notify parents as soon as possible. As the parent/guardian I accept responsibility for any additional expenses that may result from such
services.
I as the parent/guardian agree to permit reasonable use of photos and videos or other pictures of my child in promoting BCBC and its programs.
Other Medical Information
BCBC guarantees that there will be a trained medical worker on the premises each week of camp. All campers must be in good health upon their arrival at camp. To
Box 659, Riverton MB R0C 2R0 Registrar Ph. 1(888)802-7112
prevent a lice outbreak, all campers will be checked for lice as part of the registration process.
Follow-up Program
During the summer some campers develop a keen interest in Bible study and in their own spiritual development. To encourage all campers to grow in their
relationship with Jesus Christ, we enrol them in Mailbox Club. BCBC counsellors are encouraged to keep up their relationship with their campers by letters, email,
phone calls, visits and cabin reunions. We also plan fun events during the winter in the Interlake to give campers the chance to reconnect with counsellors and cabin
mates and to have a great time!
I release the use of my personal information for BCBC and its associated ministries to contact our family about events, news and information deemed pertinent by
BCBC.
DATE
/
/2015 SIGNATURE OF PARENT/GUARDIAN
Campers Promise – I agree to respect myself, others, camp/personal property and the environment. I will try my best while participating in activities and obey all
camp rules.
DATE
/
/2015 SIGNATURE OF CAMPER