Camper Registration Form 

Camper Fees: $331

Full Name *
First Name
Middle
Last Name
Age*
Birthdate*
Please list the grade you will be entering Fall 2017*
Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home Phone*
Cell Phone
Email*
Are you a first time camper to Koronis?*
Please list any friends you would like to share a cabin with
Please list any friends you are bringing to camp for the first time
Medical Form (required) Health History
Chicken Pox*
Bed Wetting*
Asthma*
Diabetes*
Ear Trouble*
ADD/ADHA*
Allergies
Insect Bites*
Please list any medication allergies *
Please list any food allergies *
Immunization Record (record date of last immunization)
Polio*
Measles*
Diphtheria*
Mumps*
Pertussis*
Tetanus*
State last illness and when *
Please list all medications your child is currently taking and any special activity limiations *
Insurance Information
Health Insurance Company*
Policy #*
Emergency Contact Name*
Emergency Contact Phone*
Medical Release In consideration of the benefits derived from Koronis Bible Camp. I hereby give my permission for the child to attend and voluntarily waive any and all claims against its sponsors, directors, and officials for any and all causes that may arise from activities of the camp. if medical attention is necessary, I agree to be responsible for all costs not covered by my insurance company. In case of emergency, I hereby give permission to the Physician, selected by the Camp Program Director, to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child named above.
Photo Release I agree that any portraits or video of the camper taken at camp may be used by Koronis Bible Camp or their assigned agents for advertising and promotional literature. I waive my right to inspect or approve the finished product or copy.
Please answer yes to agree to the medical and photo releases as stated above.*
Signature or Parent/Guardian *

Once you have completed the online registration, please send a $100 deposit to:

Koronis Bible Camp
Registrar/Jenny Sayre
128 Bridgewater Drive
Vadnais Heights, MN 55127
 

For questions regarding registration, please email registrar@koronisbiblecamp.com