Lincoln Lake Baptist Camp: summer camps

2010 On-line Registration $20 Off if registered by April 30, 2010

* Name of person filling out this form
* Camper's Full Name
* Gender
* Birthdate
* Father's Full Name
* Mother's Full Name
* Mailing Address
* City
* State
* Zipcode
* Home Phone
* Work Phone
* Email
* Church and Church's City

* Grade entering in the fall
* Camp Choice
Shirt Size
Cabin Mate Request

* Family Doctor
* Doctor's Phone
* Insurance Company
* Policy Number
* Are there any health or behavorial conditions that Lincoln Lake should be aware of?
* Medications taken regularly
* Current infectious diseases or conditions
* Allergic reactions
* Are immunizations up to date??
* Other medical concerns for your child/teen?

* I authorize my child to be picked up by the following individuals (include parent's names and/or name of church:

In case of emergency or general medical care, I give consent for medical treatment for my child, named above, by authorized personnel. The camp carries secondary accident insurance which means all claims must be submitted to the parents' insurance carrier first, then the unpaid balance will be summitted to our carrier. I understand that Lincoln Lake Baptist Camp will not release my camper to anyone without written permission. I certify the above child has my permission to attend camp and participate in all activities. I realize that my camper's picture and testimony may be used in the promotion of the camp. My child may also receive e-mails, letters, and mailings from Lincoln Lake Baptist Camp.
* I agree to the above statement


* Payment Method
* Amount to be Charged
* Card Number
* Expiration Date
* I authorize Lincoln Lake Baptist Youth Camp to charge my credit card. I understand that the amount charged to my credit card will be reflected on my credit card statement within 14 days.


For Camp Use Only: Date Received: ____/____/2010 Paid:__________ Balance:______________

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2010 On-line Registration **$20 Off if registered by April 30, 2010**

2010 On-line Registration $20 Off if registered by April 30, 2010