Camper Registration

Simmons Baptist Camp (Operated by Texas Co. Baptist Association): 5765 Camp Road
Mailing Address: PO Box 11, Houston, MO 65483 | Office Address: 17608 Hwy B, Houston, MO 65483
Office Phone: 417.967.2015 | Email: office@tcba.site | Website: tcba.site

"*" indicates required fields

Step 1 of 2

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Registration

Check which camp student will be attending (grade completed):*

Day Camp (Grades K-2nd) June 17-19, 9am-4pm daily. Check-in 8:15-9 first day.

Boys' Camp (Grades 3-6) July 10-13. Check-in 8-9am. Camp ends 11am.

Girls' Camp (Grades 3-6) July 17-20. Check-in 8-10am. Camp ends 4pm.

Youth Camp (Grades 7-12) June 14-15.

T-Shirt Size (select one):

Child Small

Child Medium

Child Large

Child XL

Adult Small

Adult Medium

Adult Large

Adult XL

Pre-registration deadlines to guarantee t-shirt: Boys' Camp June 24, Girls' Camp July 1

Camper's Name*

First Last

Address*

Street Address City State ZIP Code

Grade Completed*

Age*

Birthdate*

Month

Day

Year

Gender*

Male

Female

Name of Parent/Guardian*

First Last

Phone Number*

Okay to Text?*

Yes

Email*

Emergency Contact (other than parents):

Name*

First Last

Phone #*

Relation*

No one can sign a child out of camp other than an authorized parent, guardian, or leader from the sending church. Please list anyone authorized to pick up your child (must show ID):*

Church you are attending camp with this week:

Is this the church you regularly attend?

Yes

Church:

One camper you would like to room/group with:

Consent*

I certify that I am aware of the inherent risks associated with participating in camp activities and residing on camp property to my child. I give my child permission to participate in all organized camp activities.

I agree to be financially responsible for any damage or destruction to camp property, including, but not limited to acts of graffiti by my child. I agree that in the event my child becomes a discipline problem, child will be sent home at my expense and will forfeit all monies paid.

In consideration for Simmons Camp agreeing to accept the above-names individual as a camper, I/We further agree to release and hold harmless Texas County Baptist Association, Simmons Camp, its trustees, Camp Manager, employees for any injury, harm or other damage by any occurrence in connection with my child's participation in any form or fashion at the camp. I further agree to release and hold harmless TCBA, Simmons Camp, Camp Manager, trustees, employees from any claim by me or my family, estate, heirs or assigns out of my child's participation in activities at Simmons Baptist Camp.

I/We authorize medical and surgical treatment or hospital care to be rendered by my child as needed in the judgment of the treating physician chosen by the Camp Director or adult leader. I/We authorize the Simmons Camp first aid staff or nurse to administer medications as prescribed and programmed on the Dosage/Time Chart Forms.

I/We understand that only limited secondary accident and illness coverage is provided by Simmons Camp for off property health care needs through Doctor Office visits, hospital emergency room or ambulance service. I/We shall be liable and agree to pay all costs and associated Expenses incurred in connection with such medical and dental services rendered to my child.

I authorize to display pictures of my child in promotion of Texas County Baptist Association and Simmons Baptist Camp.

I certify that I am the parent or legal guardian of the minor on this agreement.

Signature of Parent/Guardian

I agree that my typed signature can serve as a substitute for my handwritten signature.

Date

Month

Day

Year

Camper Health

Camper Health Care Information

All prescription and non-prescription medications must be kept with the camp staff for administration in accordance with the physician's prescription and parent's instructions listed on the form. With the exception of prescription inhalers, campers are not allowed to keep or self-administer any medications. If your child requires prescription or non-prescription medications while at camp, please complete the Medication Chart.

Personal/Family Care Information

Primary Care Physician*

Phone #*

Name of Insurance Co.*

Group #*

Phone #*

Medical History/Allergies

List Any Allergies:

Is your child allowed to swim?*

Yes

Life jacket required?*

Yes

Asthma:*

Yes

If yes, list asthma medication:

Diabetes:*

Yes

If yes, list diabetic medication:

Heart Trouble:*

Yes

Fainting Spells:*

Yes

Convulsions:*

Yes

Immunizations up to date?*

Yes

Date of last tetanus shot:

Month

Day

Year

List any other conditions:

Medication List (include name, dose, time, and reason for taking)

Prescription medications must be in ORIGINAL CONTAINERS with prescription labels. Place all medications and a copy of this page in a one quart zip lock bag and turn in at registration.

Comments

This field is for validation purposes and should be left unchanged.

Registration

Camper Health

Let’s Talk!

Visit or Call Today!

17608 County Road B
Houston, MO 65483

Registration

Camper Health

Let’s Talk!

Visit or Call Today!

17608 County Road B Houston, MO 65483

17608 County Road B
Houston, MO 65483