Beulahland Christian Camp Registration
For more information about pick up and packing, please visit http://www.beulahlandbiblecamp.org/info-for-parents.html 
The donation fee for camp is $200.  Camp registration fees are due when campers arrive at camp or can be mailed to Box 35  Elgin, IA 52141.
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Email *
Week Attending *
Register for the grade completed.
Grade Completed in 2022 *
Full Name *
First and Last
Nickname
Parent Email *
Address *
City *
State *
Zipcode *
Age *
Birth Date *
MM
/
DD
/
YYYY
Sex *
T-shirt Size *
First time attending camp? *
Father's Full Name
(or male guardian)
Father's Cell Number
Father's Work Number
Father's Home Number
Mother's Full Name
(or female guardian)
Mother's Cell Number
Mother's Work Number
Mother's Home Number
Primary Contact for Emergencies *
Provide Contact information if contact information is not listed above
Photos (no names) of campers may be used on camp website to promote Beulahland Christian Camp. Campers may travel to activities off campgrounds. Do you give permission to this? *
Does the child have health insurance? *
Company
Policy Number
Family Physician
Family Physician Phone Number
Immunizations - Month & Year
N/A if not applicable
D.P.T. Series *
Tetanus *
Mumps *
Measles *
Rubella *
Other (specify) *
Allergies
Environmental *
or none
Poison Ivy/Oak *
or none
Insect Stings *
or none
Foods (Please specify) *
or none
Other
Is the Camper bringing medications to camp? *
All medications must be kept in original containers. Each container must list the recipient’s name, the name of the drug, original orders, dosages, dates, directions for use, and specifics for special storage.
If Yes, what medication?
This health history is correct to my knowledge, and the person described herein, has permission to engage in all prescribed camp activities, except those listed by me here: *
Signature of Parent/ Guardian (If camper is a foster child, the case worker must sign)
In the event I cannot be reached in an Emergency, I hereby give permission to the physician, selected by the Camp Director/ Manager, to hospitalize, secure proper treatment for, and to offer injection, surgery or anesthesia for the person named above. *
Signature of Parent/ Guardian (If camper is a foster child, the case worker must sign)
A copy of your responses will be emailed to the address you provided.
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