IBC Camper Registration 2010

2010 CAMPER REGISTRATION FORM

IOWA BIBLE CAMP 54^th ANNUAL SUMMER CAMP

June 20-25, 2010

Please forward camp application to:

Steve Swanson
3301 Terrace Drive
Des Moines, Iowa 50312
or fax to 515-274-6075

Parents: please fill out this application and the medical history form. Be sure to sign this as no child will be admitted without this signature. Mail the application to the registrar listed above - no application fee required. If your child would like to share a cabin with a friend, list on the application one or more friends who are approximately the same age as your child.

Male/Female	Birthday		Age July 1		Grade this coming fall		Phone Number
Name						First time camper? Yes No
Address
City		State				Zip Code
E-mail Address
Name of friend to share cabin				Friend's age July 1
Name of friend to share cabin				Friend's age July 1
First-time campers, please write the name of the friend who invited you for their $50/friend discount.

Mark camp fee you are eligible for:

[ ] $245 Regular camp Fee

[ ] $122.50 First-time camper Fee

[ ] $235 Early Bird Registration (postmarked prior to June 5^th)

[ ] $255 LATE Registration (postmarked after June 12^th)

[ ] $280 Shalom Center Fee

[ ] $135 Counselor in Cabin Fee (College students: contact Stefan Johnson for camp scholarship opportunities.)

(Camp fee payment with application is appreciated. Make checks payable to Iowa Bible Camp)

Counselors be sure to fill out the separate counselor application form that can be down loaded From this web site: www.iowabiblecamp.org

Medical History
Name of Camper
1. Date of last tetanus shot	6. List any heart disorders:
2.Purpose of any surgeries in the last year	7. List any allergies:
3.Check if the camper has ever had _hernia _scarlet fever _tuberculosis _rheumatic fever _kidney disorders _poison ivy _nervousness _poison oak _convulsions _poison sumac _fainting spells	8. List present injuries:
	9. Restrictions on water activities:
	10. Other activities restriction:
	11. General health _good _fair _poor
4. Does camper have athletes foot? _yes _no	12. Date of last doctor’s exam Comments:
5. Does camper wet the bed? _yes _no	13. Parent comments:

I certify I have read and filled out the above questions and my answers are correct to the best of my knowledge. In consideration of the benefits derived from the Iowa Bible Camp, I hereby give my permission for the above named child to attend the Camp and voluntarily waive any claim against its sponsor, director, and officials for any and all causes that may arise from the activities of the Camp. In the case of surgical or medical emergency, I hereby give permission to the physician selected by the Camp Director or designate to hospitalize, to secure proper treatment for , and to order injections, anesthesia, or surgery for the child named above.

Signed: _________________________________ Date: ___________

Address_________________________________ Phone_______________________

Emergency contact: _______________________________ Phone_______________________

Camp Location:
Twin Lakes Christian Center
2524 West Twin Lakes Rd
Manson, Iowa

Speakers:
Junior Camp: Arthur Manning (ages 9-12)
Senior Camp: Jon Glock (ages 13-high school graduate)

Start: June 20 - Sunday Afternoon (supper provided) Registration begins at 3:30 pm
End: June 25 - FRIDAY afternoon at 2:00 PM

Bonus Bring A Friend Program:
Bring a first time camper to Iowa Bible Camp and receive $50 discount per new camper.

Medical History

Name of Camper