JULY 12–16COVENANT HARBOR

LAKE GENEVA, WI

I give permission for my child to join the Youth of Crossroads Community Church at this Crave event, sponsored by the church, its staff and sponsors. I hereby release them from responsibility and liability for any illness or injury that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me, to consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon, dentist (as appropriate), licensed to practice under the laws of the state where services are rendered, either at a doctor’s office or in any hospital. We give full permission to Crave Student Ministries to reproduce any photography and/or video image of me/my student for promotional usage without obligation to me/my student. We have read the rules and agree to abide by them and do herby give permission to participate in all camp activities.

Please list two friends you’d like to room with.We will try our best to get at least one in a room with you.

Friend #1 Friend #2

Student Signature (Required)

¡ EARLY STUDENT PRICE – $250 (Money due by May 6)

¡ REGULAR STUDENT PRICE – $275 (Money due by June 3)

¡ LATE STUDENT PRICE – $300 (Money due by July 1)

Make checks payable to Crossroads Community Church.

PLEASE CHECK ONE

Parent/Guardian Signature (Required)

NAME: CHURCH/CAMPUS: AGE: GRADE: CIRCLE ONE: Male FemaleHOME PHONE: ( ) CELL PHONE: ( ) ADDRESS: CITY: ZIP: PARENT/GUARDIAN NAME(S): HOME PHONE: ( ) CELL PHONE: ( ) ALTERNATE EMERGENCY CONTACT: EMERGENCY CONTACT PHONE: ( ) ALLERGIES: MEDICATIONS*: PHYSICAL LIMITATIONS AND/OR SPECIAL REQUESTS:

Must complete medical insurance information in order to register. If you don’t have an insurance provider write “none”.

MEDICAL INSURANCE CO.: NAME OF POLICY HOLDER: POLICY #:

*All Medications will be turned in upon registration when leaving for camp

Please print clearly.

FURTHER INFORMATION: Contact your Youth Pastor/Leader at your Church or Campus for more information.

EMERGENCY CONTACT: Crossroads Community Church (815) 233-9004 ext. 132

• Clothes you can get dirty and throw away• Bedding (sleeping bag/pillow)• Bible / Notebook / Pen• Toiletries (toothbrush, shampoo, towel, etc.)• Swim Suit• 2 Pairs of Shoes (tennis shoes & flip flops)• Clothes / Pajamas• Flashlight / Bug Spray• Money for additional activities (although there are plenty of

free activities that do not require money)

WHAT TO BRING

1. Modest attire please (spaghetti strap tops, bare midriffs, tight and/or short garments are prohibited. Extremely modest swimwear is expected. T-shirt and shorts must be worn between activities).

2. Public displays of affection are not allowed.3. Any PRANKS, intimidation, or threats of bodily harm will be considered

grounds for dismissal from camp.4. Crave Student Ministries is not responsible for lost, damaged, or stolen items.5. Firearms, knives, weapons, or clothing and other articles displaying

questionable content are NOT allowed.6. Fireworks, smoking, alcoholic beverages, or drugs are NOT allowed.7. The daily schedule must be observed by all. No one is to leave the camp

grounds without special permission.8. All medications, prescriptions and over the counter drugs must be turned in

during registration.

These are provided for the safety of everyone attending camp. Failure to follow these rules will lead to dismissal from camp at camper’s expense.

EXPECTATIONS

CONTINUED ON BACK

APPLICATION FORM✁