UMW: Youth Retreats 2024-2025

Camper Information

Name

Gender

Male
Female
Gender Queer

Pronoun Preference

If other, please state here.

Date of Birth

Current Grade

Address

Is this your first time 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.

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:

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 it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

The camper will not take any daily medications while attending camp.

The camper will take the following daily medications while at camp:

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)

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

Retreat Session and Payment Options

Please select the retreat you plan to attend:

Chi Rho - Grades 6-8 ($100.00)
CYF - Grades 9-12 ($100.00)

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

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.

Unless checked below, I accept that the participant/s likeness may be used in any online or print publications or social media by the Christian Conference Center and/or the Christian Church in the Upper Midwest.

I DO NOT give my consent.

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address