Contact Randy Sutton for more info:

903.645.3515 brorandy@southunion.org

Campground info:

Pine Springs Baptist Camp

3386 FM 1798 W

Laneville, TX 75667

903.863.5524

www.pinespringsbaptistcamp.com

REGISTRATION & MEDICAL FORM

Camper’s Name:

_____________________________

Age:____ Gender:_________

Grade just completed: 2nd 3rd 4th 5th

Church Name:

___________________

Sponsor’s Name:

_____________________________

T-Shirt Size: (please circle)

YM YL S M L XL XXL XXXL

Will camper be taking

medication while at camp?

YES / NOMedicine:

_____________________________

Dosage:_______________________

Time of Day:____________________

Medicine:_____________________________

Dosage:_______________________

Time of Day:____________________

Allergies:

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Medication must be turned over to the

nurse upon arrival at camp.

ABSOLUTELY NO MEDICINEWILL BE ADMINISTERED

UNLESS IT IS IN THEORIGINAL/PRESCRIPTION PACKAGING.

If the camper has recently been under a

doctor’s care, has any special health prob-

lems, handicaps, or has any behavioral

problems, please attach an explanation.

Circle illnesses your child has had:

Measles, Mumps, Typhoid, Scarlet Fever,

Polio, Diphtheria, Whooping Cough,

Kidney Ailments, Chicken Pox

In case of emergency notify:Parent or Guardian:

_____________________________

Address:

_____________________________

City/State/Zip:

_____________________________

Home Phone:___________________

Work Phone:____________________

Cell:__________________________

Secondary emergency contact:Address:

_____________________________

City/State/Zip:

_____________________________

Home Phone:___________________

Work Phone:____________________

Cell:__________________________

CAMP FEE $125 2017

June 19-22, 2017Pine Springs Baptist Camp

2017 CAMP SCHEDULEMONDAY1:00pm – Registration2:00pm – 4:00pm – Concession Stand Open1:15pm-2:45pm – Girls Swim Time*3:00-4:30pm – Boys Swim Time*3:00pm - Sponsor’s Meeting5:00pm-6:00pm – Supper6:30pm-7:15pm – Ignition (Introductions, Worship & Praise)7:20pm-7:45pm – Team Time Event7:45pm-9:00pm – Free Time*7:45pm-8:30pm – Concession Stand & Gift Shop Open9:00pm-9:45pm – Last Call9:45pm-10:00pm – Church Time10:00pm - Cabins

TUESDAY – WEDNESDAY8:30am – Breakfast9:30am-10:15am – Surge (Main Worship)10:20am-10:30am – Team Time (Small Group)10:35am-11:35am – Team Challenge (Competitive Games)11:35am-12:00pm Free Time*12:00pm-1:00pm – Lunch1:00pm-1:45pm – Power Up (Object Message)1:45pm-5:00pm – Free Time*2:00pm-4:00pm – Concessions Stand Open2:00pm-3:00pm – Girls Swim Time*2:30pm-3:00pm – Boys Craft Time* (Tuesday only)2:30pm-4:00pm – Carnival Games* (Wednesday only)3:15pm-4:15pm – Boys Swim Time*3:30pm-4:00pm – Girls Craft Time* (Tuesday only)5:00pm-6:00pm – Supper6:30pm-7:00pm - Converge7:00pm-7:30pm – Main Team Time & Adult Prayer Time-Cafeteria7:30pm-9:00pm – Free Time*7:30pm- 8:30pm – Concession Stand & Gift Shop Open7:30pm-8:30pm – Movie Time*9:00pm-9:45pm – Last Call (Group Game & Decision Celebration) 9:45pm-10:00pm – Church Time10:00pm - Cabins

THURSDAY8:30am – Breakfast9:30am-10:15am – Surge (Main Worship)10:20am-10:30am – Team Time (Small Group)10:35am-11:35am – Team Challenge (Competitive Games)11:40am-12:00pm - Closing12:00pm-1:00pm – Lunch1:00pm – Campus Clean Up

*Optional activities

Medical Insurance:In the event that medical care is needed,

please fill out the following personal medical insurance information.

Company name:

_____________________________

Policy #: _______________________

Phone:________________________

Address:

_____________________________

City/State/Zip:_____________________________

Have doctor bill me:

Parent or Guardian:

_____________________________

Address:

_____________________________

City/State/Zip:

_____________________________

Signature:______________________

Date:_________________________

State of Texas Law Requirements:Are you 18 years of age or older?

YES / NOHave you ever been convicted of a

felony or a misdemeanor?

YES / NOIf yes, please contact the office of Pine Springs Baptist Camp for additional

information on attending.

Consent for medical treatmentand Visual Image Permission:

I give full permission for my child to

attend Pine Springs Baptist Camp and

to take part in all activities. My child will

not attend if he/she has been exposed to

a contagious disease, or if he/she is not

in good physical condition. I do not hold

the Camp Personnel and/or Sponsors

responsible for any accident or illness;

and if necessary, I authorize the camp

personnel or sponsor to take my child

to a physician or hospital. I also give

my full consent for the doctor to render

professional services to my child, if he

or she becomes ill or is involved in an

accident. I also grant permission for my

child to be photographed and/or filmed while at camp. The photographs

and/or film will remain the property of Elevate camp and may be used in camp

media, publications, or website. If the

above named camper is age 18 years or

older, I grant authorization to perform the

necessary background check as required

by the State of Texas.

Signature of Parent or Guardian:

___________________________

Date:_______________________