Register for Summer Camp

Name *

Gender *MaleFemale

Age *

Date of Birth *

Month

Day

Year

Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone *

Parent / Guardian *

Emergency Contact Name *

Emergency Contact Phone *

Relationship of Emergency Contact *

Pickup Person *

Church *

Date of Last Tetanus Shot *

Do you have insurance? *YesNo

Insurance Provider *

Name of Policy Holder *

Policy Number *

Are you Current on Immunizations? *YesNo

Dietary Needs

Alergies

Medications

Do you have any of the following? *YesNo Sleepwalk, Faint, Epilepsy, Diabetes, Asthma

Do you Sleepwalk *YesNo

Do you Faint *YesNo

Do you have Epilepsy *YesNo

Do you have Diabetes *YesNo

Do you have Asthma *YesNo

Pre Existing Medical Conditions

Other Important Information

How do you plan to pay? *OnlineMailWhen you arriveI have a full schoarship

Permission Statement – By clicking submit below, I GIVE PERMISSION for Whispering Winds Bible Camp (WWBC) to secure medical treatment for myself, my spouse, or my child in case of illness or accident. I GIVE PERMISSION for my child to participate in all Camp activities, both on and off camp property, either by walking or riding in camp vehicles, including (without limitation): hiking, backpacking, canoeing, kayaking, caving, water tubing, low ropes course, climbing wall and swimming. I ACKNOWLEDGE AND ACCEPT the risks involved in camping activities for myself, my spouse, or my child. I ACCEPT personal financial responsibility for any bodily injury sustained by myself, my spouse, or my child while at WWBC. Furthermore, I PROMISE to hold harmless WWBC and its representatives for any injury related to Camp. I GIVE PERMSSION for my child to receive Bible-based instruction while at WWBC. I AGREE for myself, my spouse, and my child to abide by the dress standards and rules of conduct of WWBC. I GIVE PERMISSION for WWBC to use pictures including myself, my spouse, or my child in organizational publicity. *I Agree

Type Name as Signature *

Parent or Guardian if under 18