Registration Form (continued)
Name of Insurance holder:
_______________________________________________
Insurance company's address:
_______________________________________________
Insurance holder's SS#: ___________________________
Family Physician: ________________________________
Physician's Phone: _______________________________
Registration cannot be processed without the signature
of the camper's parent or guardian on this release form.
Incomplete forms will be returned.
I consent to examination and treatment of my child(ren)
by any medical personnel deemed necessary by Family
Bible Camp. I understand that every effort will be made
to contact parents or guardians of campers in the event
of emergency. In the event that I cannot be reached, I
hereby give permission to the physicians selected by
Family Bible Camp to hospitalize; secure proper
treatments; and order injections, anesthesia, or surgery
for my child(ren) as named.
Date: ______________________
Parent signature:_________________________________
Mission Statement
Crossroads Baptist Camp is a ministry of
Crossroads Baptist Church and is
committed to reaching young people with
the Gospel and then challenging them to
live a Christ-like life. We are committed
to provide a fun and quality camping
experience at the lowest possible price.
ROPERS
Camp Director
Pastor Rick Moore
Program Director/Camp Evangelist
VS
WRANGLERS
Evangelist Jake D’Andrea
Detach this form and mail to:
10027 W. 1000 S. Wanatah, IN 46390
Keep the rest of the brochure for your records.
*For the protection of all campers, campers with lice are
unable to be retained on the premises.
**For promotional purposes, Family Bible Camp
reserves the right to use any photographs taken while
your child is at camp.
For office use only:
 Medical form | Date postmarked ___________
Cash
 Check/Money order # __________
Paid by: _________________________________
Total amount of check: _____________________
Amount applied to camper: _________________
A Ministry of
10027 W 1000 S | Wanatah, IN
219.733.1500 | cbcwanatah.com
[email protected]
June 22-27, 2015
CROSSROADS BAPTIST CAMP
Registration Form
The Wild West
Age: Campers going into the 5th grade
through those who have just completed 12th
grade.
Camper Cost: $125.00 by June 1st, 2015
After June 1st, 2015 - $150.00
Arrival: Monday 2:00-4:00PM (CST)
Departure: Saturday 10:30AM (CST)
Please mail registration form and $25.00
registration fee to the address on registration
form. A multi-child discount of $25.00
will be given to families with two or more
children attending camp (first child $125
additional children $100 per child).
Dress
Guys: For daily activities, tank tops are not
permitted, and shorts must reach the tops of
the knees. Casual pants or clean, nice jeans
(no torn jeans) and collared shirts must be
worn to each evening service.
Girls: All clothing worn for daily activities
must reach the tops of the knees. Loose fitting pants are acceptable for recreation.
Knee-length skirts or dresses must be worn to
each evening service (please, no slits above
the knees). Modest tops must be warn at all
times. No tank tops.
Note: This camp maintains conservative
standards for dress and conduct. We reserve
the right to request a change in any clothing or
behavior we deem inappropriate.
Activities
Archery, Basketball, Big Ball, Campfire, Capture
the Flag, Fishing, Frisbee, Fun Night, Kickball,
Night Games, Skit Night, Snack Shop, Swimming,
Volleyball, Water Balloon Slingshots, Three Ball,
Water Wars, and More!
What to Bring
Twin-sized sheets or sleeping bag, pillow, towels,
toiletries, clothes for warm and cool weather,
extra clothes, tennis shoes (for rugged activities),
extra pair of shoes, one-piece swimsuit, jacket,
Bible, notepad, pen or pencil, spending money,
camera, flashlight, alarm clock, fan,
insect repellant
Do Not Bring
TV, MP3 players, I Pads, I Pods, tablets,
computers, cell phones, video games,
magazines, tobacco, clothes with inappropriate
writing or music groups.
Directions
Crossroads Baptist Camp is held at Michiana
Baptist Camp in Shipshewana, IN. Take 80-90 toll
road to exit 107 (St. Rd. 13). Turn south (right).
At fourth stop light (CR 16 or Warren St.) turn
east (left). Go 7 miles to 900 W. and turn north
(left) follow around the lake past houses. Camp
entrance will be on the left. The address of the
camp is 3190 North 915 West, Shipshewana, IN
(DO NOT MAIL CAMP FORM TO THIS ADDRESS).
Camper's Name: ______________________
Gender: M F
Age: ________
Date of Birth: _________________
Grade in the fall __________
Mailing Address: ______________________
City: ________________________________
State: _____ Zip: ___________
Email: _______________________________
Home Phone: (______)_________________
Cell: (______)_________________
Parent/Guardian camper lives with:
____________________________________
Work Phone (______)__________________
Emergency Contact ____________________
Emergency Phone (______)______________
Home Church: ________________________
Church Mailing Address: _______________
City: ____________ State: ____ Zip: _____
Church Phone: (______)________________
Pastor's Name: _______________________
Pastor's Phone: (______)________________
Medical Form:
Date of Last Tetanus Booster: ___________
Prescribed Medication Taken Regularly:
____________________________________
____________________________________
____________________________________
Reason for Taking Medication: __________
____________________________________
____________________________________
Specific Allergies: _____________________
____________________________________
____________________________________
Type of Reaction: _____________________
____________________________________
____________________________________
Does your Child Have Asthma? __________
Will your child bring an inhaler? _________
Specific activities to be restricted
(please give reason):______________________
________________________________________
________________________________________
________________________________________
________________________________________
Crossroads Baptist Camp 2015
T-Shirt Order Form
You have the option to order a team t-shirt for your child bearing the camp theme and their team logo. Should you
choose to order a t-shirt for your child, this order form along with the $12.00 t-shirt cost should be received no
later than May 1st. Please send one order form per camper.
Camper Name: __________________________________
Quantity _________
Size (circle one)
Youth S M L XL
Adult S M L XL XXL
You do not need to select a color. The t-shirt will be red or blue depending upon the team that your child is on.
Please return this form along with $12.00 no later than May 1st.
Send to:
Crossroads Baptist Church
Attn: Camp
10027 W. 1000 S.
Wanatah, IN 46390