UMW: CCC Family Camp Out

Christian Conference Center

Family Camp Out

Every individual that plans to attend must complete a registration form. If you have any questions, please contact Crystal at 515.367.0440 or [email protected].

Camper Information

Name*

Date of Birth*

Address*

Allergy Information

Allergy Information*

No known allergies
Tree Nuts
Nuts
Gluten
Shellfish
Red Dye 40
Other Food
Medicine
Environment
Other

Please describe what the camper is allergic to, the reaction seen, and how it is treated.

Diet/Nutrition

Diet/Nutrition Needs*

This camper eats a regular diet.
This camper eats a gluten-free diet.
This camper eats a vegetarian diet.
This camper eats a red-dye 40 free diet.
This camper has other special food needs.

Please describe any special food needs.

Restriction Information

Restriction Information*

I have reviewed the program/activities and feel that the camper can participate without restrictions.
I have reviewed the program/activities and feel that the camper can participate with restrictions.

Please describe restrictions:

Parent or Legal Guardian Information

Parent or Guardian Name*

Relationship to Camper*

Address (if different from camper)

Phone Number*

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. View our terms of service & privacy policy.

Email (this will be used for camper communication)*

Secondary Emergency Contact

Secondary Emergency Contact Name*

Relationship to Camper*

Phone Number*

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. View our terms of service & privacy policy.

Email

Payment

Family Camp Out*

Family Camp Out ($50.00)

Please list all family members lodging with you:

***Each person attending must fill out a registration form!***

Children ages 3 and younger are free to attend with their family. Please complete a registration form for the child and enter UNDER3CAMPER in the coupon code box.

Family Camp Out Coupon Code

Total

$0.00

Authorization Information

By signing you agree to the responsibility and supervision of your participants and yourself. CCUM/CCC is not liable for any loss, damage, injury, or claims arising out of participants' acts or omissions.

There will be lifeguards at the lake.

By typing my name here, I accept these terms.*

Do we have permission to use the camper's photograph in online or print publications, or in social media by the CCC and/or the CCUM?*

Yes
No

We are able to keep our events affordable because of donations from generous supporters. Every gift helps us fulfill our mission to provide a safe, welcoming experience to as many people as possible. Thank you!

Donation Amount

Suggested Amounts

$5
$10
$15
$20
Other Amount

Add 3% to my donation to cover credit card fees.

Total

$0.00

Billing Information

Email*

Name*

Credit Card*

Visa
Mastercard
American Express
Discover

Address*

RegFox Event Registration Software

Event Registration Software by RegFox