Grindstone Lake Bible Camp Registration

All fields marked with * are required.

Camper Name* First Last
Sex*
Age*
Birth Date of Camper* / MM / DD YYYY
Email Address*
Please place a check by the week that you wish to register* June 17th - 22nd
4th – 6th Grade I Week June 30th - July 4th
1st – 3rd Grade Week July 8th - 13th
7th – 9th Grade Week July 15th - 19th
3rd – 5th Grade Week July 16th - 20th
K-2 Day Camp Week† July 22nd - 27th
10th - 12th Grade Week August 5th - 10th
6th – 8th Grade Week August 12th - 17th
4th - 6th Grade II Week
†This is a day camp from 8 AM to 6 PM. Campers do not stay overnight.

If attending day camp (K-2nd Grade), which day(s) do you plan to attend?

If signing up for other weeks, please skip this question
I would like to room with

Camp does not normally honor group requests of four or more.

Address*

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Name of Parent(s) or Guardian*
Home Phone*
Second Phone
Your Church
Church City
Has this child attend GLBC in the last three years?*
Would you like to receive the GLBC News & Notes on a quarterly basis?*
Emergency Contact (other than parent)*
Emergency Contact Phone*
Insurance Carrier

NA if cannot provide.
Policy No.

NA if cannot provide.
Physician's Name and Phone Number

NA if cannot provide.
Immunizations:
Diphtheria*
Polio*
Measles*
Mumps*
Whooping Cough*
Rubella*
Date of Last Tetanus*
Health History:
Chicken Pox*
Asthma*
Convulsions*
Epilepsy*
Ear Trouble*
Emotional Problem*
Diabetes*
Heart Trouble*
Skin Problems*
Allergic to:
Penicillin*
Insect Stings*
Other (please explain below)*
List any activity restrictions and/or medication your child takes:

Medical Release: Parents, please type your name below. This typing of your name authorizes all hospital/medical treatment when deemed necessary by the camp for the welfare of the camper. I am aware that my child may be used in promotional pictures. The information on this form is correct to the best of my knowledge.

Statement Verification*
Name of Person Picking Camper Up
(This person will be required to sign out your child.)*

Grindstone Lake Bible Camp Registration

Grindstone Lake Bible Camp Registration

Immunizations:

Health History:

Allergic to: