Medical Information/Consent
The following MUST be filled out by a parent or guardian, as required by Camp Illiana.
Name________________________________________ Date of last Tetanus Booster___________
Allergies, including medicines ______________________________________________________
Current medications your child is taking:______________________________________________
ALL MEDICINE MUST BE IN ORIGINAL CONTAINER & MARKED CLEARLY WITH CHILD'S NAME. A MEDICAL DOSAGE FORM
(available on registration day) MUST ALSO BE FILLED OUT WITH DETAILED DOSAGE INSTRUCTIONS.
Please list any non-prescription medications you DO NOT wish your child to have:____________
______________________________________________________________________________
Please list any restrictions that would hinder your child from participation in camp activities:
Middle School
Summer Camp
______________________________________________________________________________
Please list any emotional stress your child has recently experienced: ________________________
______________________________________________________________________________
Health Insurance Co. ___________________________ Policy # __________________________
IN CASE OF AN EMERGENCY: I hereby give permission to the physician selected by camp management to
hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child named on this
form. I understand, however, that every effort will be made to contact me in case of an emergency and before
any such treatment is administered. I release and hereby agree to hold blameless Crossroads Christian Church,
Camp Illiana and its directors and agents from any and every claim arising, or which may be asserted by me or
by any member of my family by reason of participating in any activities associated with Camp Illiana, including
the adventure elements. I hereby release the camp from any responsibility other than normal supervisory care. In
case of an accident, I will not hold Crossroads Christian Church, Illiana Christian Assembly or its staff members,
management, or officers liable unless guilty of negligence.
Name of Father ______________________________ Phone # ___________________________
Name of Mother ______________________________ Phone # ___________________________
Emergency Contact____________________________ Emergency # _______________________
Signature of parent/guardian ____________________ Date ______________________________
(Signature also gives permission to use your child's picture in promotional materials.)
Camp Code of Conduct
1. The possession and use of tobacco, alcohol, illegal drugs, or any substance to be ingested
or inhaled to produce a "high" are not permitted on the camp grounds. Anyone possessing or
using such items will be sent home immediately.
2. Illness or injury must be reported to the camp nurse immediately. ALL medications, regardless
of type, are to be dispensed by the camp nurse.
3. Cell phones, music players, video games, knives, comic books, magazines, pets, etc. are all to
be left at home.
4. Clothing: Modesty and decency must prevail. Short or tight shorts, bare midriff, or revealing
clothing are not permitted. No spaghetti strap tops. Swimsuits must be one piece.
5. Food and drinks are NOT ALLOWED IN THE DORMS.
6. Campers and their parents/guardians will be held responsible for any unnecessary damage to
the camp property.
7. Telephone is for emergency use only.
8. Christian conduct is expected at all times.
I have read and fully understand the above code of conduct and I agree to abide by it.
__________________________________________ _____________________________________
Camper Signature
Parent Signature
June 7-12, 2015
Middle School Summer Camp Registration
Student’s Name_______________________________________________
Dear Parents,
Thank you for considering summer camp for your Middle School
student. This event has as much potential spiritual impact as anything
else we do throughout the year. This year we’ll be looking at the
different tactics that Satan uses to Sabotage us, and how we can avoid
the traps he sets for us.
To register your child, please complete this registration form and
return it to Crossroads with a $50 deposit. (Checks should be written
to Crossroads Christian Church.) This deposit is non-refundable. The
remaining balance is due on or before Sunday, May 31st. Please note
that NO registrations will be accepted after May 31, 2015.
The church has a bus scheduled on Sunday, June 7th, to take students
from Crossroads Christian Church to Camp Illiana. The bus will return
students to the church on Friday, June 12 @ 3:30pm. If you have any
additional questions about camp, please contact Lesli Wheeler at
[email protected] or 812-518-1442.
In Christ,
Mark Silen
Middle School Pastor
Early bird price is $250 through May 17th
From May 18th to May 31st the price is $280.
(No registrations will be accepted after May 31st.)
• Cost includes transportation, lodging, and all meals.
• Registration will be in the Gym on June 7th at 1:30 PM. Please enter
through the church, as all other doors will be locked.
• Please return completed form & your $50 deposit by May 31 to
Crossroads Christian Church, 10800 Outer Lincoln Avenue, Newburgh.
• For more information about this and other Middle School events,
please visit us at www.cccgo.com/middleschool.
Address_____________________________________________________
City________________________ State __________ Zip _____________
 Home
Birthdate _______________Student’s phone #_________________  Cell
Parent’s Name(s)______________________________________________
School___________________________ Grade in the FALL ___________
My child attends Crossroads Christian Church  Yes  No
If not, the church we normally attend is____________________________
My child has made a decision to accept
Christ as his/her personal Savior.............  Yes  No
My child has been baptized.......................  Yes  No
T-Shirt Size (Adult sizes): _________
ROOMING
“IT” groups (workshops)
Please list 3 friends
with whom you’d
like to room:
To indicate your 1st, 2nd, and 3rd picks, please
place a 1, 2, and 3 next to the IT Groups of your
choice. (You will be assigned only one.)
1.__________________
____ ACT IT: Develop your gift of acting
____ BAKE IT: Bakin’ up some yummy creations
____ BEAD IT: Get your bling on
____ COOK IT: Favorite dishes are on the menu
2.__________________
____ CREATE IT: Create artistic masterpieces
____ DANCE IT: You got to move it, move it
____ DO IT: Do It Yo’self projects
3.__________________
We can only guarantee
that you will be placed
with at least one of the
friends above.
____ FISH IT: And the catch of the day is...
____ GAME IT: Youth group games on tap
____ GRILL IT: Grillin’ gourmet (not Galloping Gourmet!)
____ TAPE IT: Duct tape uses galore
____ TARGET IT: Archery basics