Southern Wesleyan University

Central, SC

June 26-30, 2023

Before completing this registration, you will need the following information: Emergency Contact Information and Medical Insurance Information. You must also be over the age of 18 and/or be the Parent or Legal Guardian of a minor participant. Registration fees are collected from your church or the organization you are coming to camp with.

If your church or group name is not listed, please first contact your Student Ministry Leader or email [email protected] to register.

Church/Organization

This registration is for a:

Participant Name

Date of Birth

Participant Phone Number

Home Address

Grade entering in the fall:

Gender

Male
Female

T-Shirt Size

Will this participant be 18 on or before June 30, 2023?

Participant Medical Information

This participant has dietary restrictions or food-related allergies

This participant has non-food-related allergies

Medications Currently Taking:

Medical Conditions

Medical Insurance Carrier and Policy Information

Emergency Contact

Relationship to Participant

Emergency Contact Phone Number (not already listed on the form)

Relationship to Participant

Secondary Emergency Contact (Other than already listed):

Relationship to Participant

Phone Number (other than already listed)

Code of Conduct

Due to this registration being for a participant under the age of 18, parents or legal guardians are responsible for sharing this information with participants. Agreeing to the terms below the Code of Conduct PDF states that you have discussed this information with the participant.

Code of Conduct

I, the undersigned, agree to the terms above.

Liability Waiver

Liability and Medical Release WP

I, the undersigned, agree to the terms above.

Liability and Medical Release

I, the undersigned, agree to the terms above.

Name of Signee

Relationship to Participant

Release of Confidential Information

Information Release

I, the undersigned, agree to the terms above.

Name of Signee

Relationship to Participant

After completing this form, please check your spam or promotions folder to access your confirmation email.

Almost done. Where should we send the confirmation?

Name

Phone Number

Questions? Email [email protected]

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