UMW: Summer Camp 2025

Christian Conference Center

2025 Summer Camps

Every individual that plans to attend camp must complete a registration form (this includes each person attending Family Camp and both grandchild(ren) and grandparent(s)for Grand Camp). If you have any questions, please call the regional office at 515-255-3168 or email [email protected]. May 1, 2025 is the LAST DAY for early bird registration. There will be a $25 late registration fee added to all registrations received after this date. Thank you!

Camper Information

Name

Gender

Male
Female
Gender Queer

Pronoun Preference

If other, please state here.

Date of Birth

Grade to be Completed in 2024

Address

Is this your first year at camp at the Christian Conference Center?

Name AND City of your church

Allergy Information

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.

Vaccination History

Are the camper's immunizations/vaccinations up to date?

If no, please explain:

If you are registering an adult for Family Camp, Grand Camp, or Senior Adult Retreat, you may omit the emotional/social health and questions 1-13 on the general health and wellbeing.

Emotional/Social Health

Has the camper ever been treated for Attention Deficit Disorder or Attention Deficit/Hyperactivity Disorder?

Has the camper ever been treated for emotional or behavioral difficulties or an eating disorder?

During the past 12 months, has the camper seen a professional to address mental/emotional health concerns?

Has the camper had a significant life event that continues to affect the camper's life?

Does the camper have a Section 503 or an IEP?

We ask so that we can make any necessary adjustments to ensure the camper has a great experience. If you are willing to share, please email it or necessary details to [email protected]. Please put IEP or 503 in the subject line. This will ensure that it is only seen by the regional minister, with necessary details shared with the camp director(s).

Please explain any "yes" answers:

General Health and Wellness Questions

Has/does the participant:

1. Wear glasses, contacts, or protective eyewear?

2. Had mononucleosis (mono) during the past 12 months?

3. Have a history of bedwetting?

4. Have problems with falling asleep/sleepwalking/nightmares?

5. Had headaches?

6. Have any skin problems?

7. If female, have problems with periods/menstruation?

8. Ever been hospitalized?

9. Ever had surgery?

10. Have recurrent/chronic illnesses?

11. Have a recent infectious disease?

12. Had a recent injury?

13. Had asthma/wheezing/shortness of breath?

14. Have diabetes?

15. Had seizures?

16. Has fainting or dizziness?

17. Ever had back/joint problems?

18. Passed out/had chest pain during exercise?

19. Have problems with diarrhea/constipation?

20. Traveled outside the country in the past 9 months?

Please explain any "yes" answers, noting the number of the question.

Medication and Medication Treatment

"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. All medications are collected, stored, and distributed by camp health care personnel. Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring only enough medications to last the entire time at camp. Keep medications in the original packaging/bottles that identify the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

Will this camper take daily medication while at camp?

If yes, the camper will take the following daily medications:

Medication Treatment

Camp staff has permission to administer over-the-counter medications as necessary.
Camper should NOT be given any over-the-counter medications.
Camp staff has permission to administer over-the-counter medications as necessary, except:

Except the following

Healthcare Providers

Primary Doctor

Doctor 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. View our terms of service & privacy policy.

Dentist

Dentist Phone Number

Orthodontist

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

Email (this will be used for camper communication)

Secondary Emergency Contact

Secondary Emergency Contact Name

Relationship to Camper

Phone Number

Is the camper covered by family medical/hospital insurance?

Of so, indicate carrier or plan name.

Policy or Group #

Name of Policy Holder

Policy Holder Date of Birth

Camp Session and Payment Options

Grand Camp and Family Camp: Please list all family members lodging with you:

***Each person attending Grand or Family camp must fill out a registration form!***

For Family Camp, the maximum fee per household is $360. If you are registering 4 people or more , please enter the following coupon code on each family member's registration.

4 Family Members Registering: FAMILY4
5 Family Members Registering: FAMILY5
6 Family Members Registering: FAMILY6

Also, 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 Coupon Code

If your church pays half of your registration, type CHURCH50. If your church pays all of your registration, type CHURCH100.

For any other coupon code, please enter it here.

Registration After May 1, 2025 ($25.00)

Other Coupon Codes

Regional camp scholarships are available! Please contact Lisa Grace ([email protected]; 515.255.3168) for more information and to request one.

Lodging Options: For Grand Camp and Family Camp only: Lodging is provided in our air conditioned cabins; however, if you would prefer, you may reserve a hotel-style Lodge Room for an additional $100 fee (1 fee per room). Note: Only one (1) camper needs to select the option below for each room.

Lodge Room Upgrade for Family Camp ($100.00)

Lodge Room Upgrade for Grand Camp ($60.00)

Running Total

$0.00

Total

$0.00

Authorization Information

You will be contacted if:

Your child is exposed to a communicable disease.
Outside medical attention is necessary (e.g. if we transport your child to a hospital or doctor's office).
Your child is having discipline problems that jeopardize the safety of others.

The undersigned person represents that he/she is the custodial parent/legal guardian of the above identified participant. The camper has my permission to attend this session of camp at the Christian Conference Center. This permission is given by me with full knowledge of the conditions and activities contemplated during each session (see uppermidwestcc.org for more information). The participant has no physical or mental disabilities that would impair their participation except as noted above. I acknowledge, agree to, reconfirm, and incorporate herein by reference the Release of Liability signed by me which is attached hereto. I also understand that the information provided on this form will be kept confidential and shared only as necessary to provide care of the participant.

I understand that camp insurance is a supplemental policy only. It will pay whatever my own insurance does not cover (deductible or over) up to the limit of the policy. If medical (sickness. injury) care is needed, billing will be sent to the parent/guardian who will be responsible for direct payments to physician, hospital, clinic, etc.

The participant is currently taking only medications listed above. The camper has no allergies known to me except as noted on this form. The health information/history is correct as far as I know. In the event of illness or injury, I authorize the camp, physician, and/or hospital to undertake such treatment of and perform such services (including surgical) for the participant as are reasonably indicated by the circumstances.

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?

We are able to keep our summer camps affordable for our families because of donations from generous supporters. Can you help us keep camp costs down? Every gift helps us fulfill our mission to provide a safe, welcoming Christian camp experience to as many campers as possible. Thank you!

Total

$0.00

Refund Policy: If the camper must cancel or cannot switch to a different camp, the registration fee, minus a $20 processing fee, will be refunded. If your church has paid, the refund will go to them to be dispersed as they deem fit.

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address