Register "*" indicates required fields Step 1 of 10 10% Guardian InformationGuardian Name* First Last Guardian Phone Number*Relationship to Camper* Guardian Email Address* Camper InformationName* First Last Name Camper Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Camper’s Home Address* Street Address Address Line 2 City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code School* School Grade*Select School GradeFirst GradeSecond GradeThird GradeFourth GradeFith GradeSixth GradeT-Shirt SIze*Select T-Shirt SizeYouth SYouth MYouth LAdult SAdult MAdult L Tells us about the CamperTalents/Hobbies/Interests:*Behavior Concerns/Fears:*Does your child have any special dietary needs?* Yes No Special Dietary Needs:*Is there anything non-medical you want us to know about your child that will help us with his/her care?* Yes No Please describe any non-medical you want us to know about your child that will help us with his/her care:* Swimming/Car SicknessSwimming Ability*Select Swimming AbilityLevel 1: Non-swimmer (Needs a life jacket at all times)Level 2: Beginner (Some swimming skills and needs a life jacket swimming in deep water)Level 3: Intermediate Swimmer (Learning and may need a life jacket)Level 4: Good Swimmer (Confident swimmer and does not need a life jacket)Level 5: Advanced (Skilled swimmer)Rate your child’s tendency for car sickness. (0 never-5 vomits)*Car Sickness Tendency0 (Never)12345 (Vomits) Camper SurveyTo help us know if we are meeting the needs of our campers and to help us better prepare for this summer and future camps, we ask that you take a few minutes to respond to the following questions: Approximately how many times has your child gone horseback riding?*Never1 time2 to 3 times4 to 5 timesMore than 6 timesApproximately how many times has your child gone fishing?*Never1 time2 to 3 times4 to 5 timesMore than 6 timesApproximately how many times has your child gone camping??*Never1 time2 to 3 times4 to 5 timesMore than 6 timesApproximately how many times has your child participated in guided nature studies?*Never1 time2 to 3 times4 to 5 timesMore than 6 timesApproximately how many times has your child participated in archery?*Never1 time2 to 3 times4 to 5 timesMore than 6 timesWill your child receive literacy instruction other than what is provided at Bound for Glory Camp this summer?* Yes No Will your child attend summer programs other than Bound for Glory Camp this summer?* Yes No What does your child hope to accomplish at Bound for Glory Camp?*What do you as the parent/guardian hope your child will accomplish at Bound for Glory Camp?* List persons that are allowed to pick up your child from camp.Approved person 1 name* First Last Approved person 1 Phone*Approved person 1 Relationship* Approved person 2 name* First Last Approved person 2 Phone*Approved person 2 Relationship* Approved person 3 name First Last Approved person 3 PhoneApproved person 3 Relationship Emergency Contact InformationEmergency Contact 2 Name* First Last Emergency Contact 2 Phone Number*Relationship to Camper* Emergency Contact 3 Name* First Last Emergency Contact 3 Phone Number*Relationship to Camper* Health HistoryDoes your child have any known allergies?* Yes no Please list your all known allergies of your child:*Health informationCheck all that apply Asthma ADD/ADHD Cancer Physical Disabilities Sickle Cell Seizure Disorder Diabetes Other physical or mental health issues which may be of concern while at camp Other physical or mental health issues*Will your child be talking any prescription medications while at camp? Yes no Prescribed Medications*Will any prescribed medications require administration during camp hours or weekend sleepovers?* Yes no Authorization to Give Prescribed Medication PDF is required by the first day of camp. Please have your child's pediatrician complete the following form for our staff to administer prescription medications. Download HereWill your child be talking any non-prescription medications while at camp? Yes no Non-Prescribed Medications*Date of last tetanus shotMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please provide a copy of camper’s insurance/Medicaid card.Insurance/Medicaid card FrontMax. file size: 100 MB.Insurance/Medicaid card BackMax. file size: 100 MB. Emergency Care AuthorizationCampers Name* First Last Child’s Healthcare Provider* First Last Healthcare Provider Phone*Emergency Medical Care Authorization: I hereby give permission to Bound for Glory Camp to contact a doctor or emergency medical service and for the doctor, hospital or medical service to provide emergency medical or surgical care for my child should an emergency arise. It is understood that the Bound for Glory Camp staff will make a conscientious effort to locate the parent/guardian or emergency contact listed on the registration document before any action will be taken. If it is not possible to locate the emergency contact listed, I will accept the expense of emergency medical or surgical treatment. Signature of parent/guardian*Date Of Signature*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I give permission to the staff of Bound for Glory Camp to administer the following over the counter medications according to label instructions. Check all that you permit: Advil/Tylenol Type Medication Bug Spray Sunscreen Antibiotic Cream Rash Cream Sunburn Lotion Antiseptic Spray Benadryl Signature of parent/guardian*Date Of Signature*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Field Trips/Camping/ExcursionsBound for Glory Camp will take off-campus trips. I give permission for my child to be transported by a Bound for Glory Camp staff member and to attend all outings. *Additional release forms are included for each excursion in which Bound for Glory Camp hires a company. Field Trips/Camping/Excursions*Bound for Glory Camp will take off-campus trips. I give permission for my child to be transported by a Bound for Glory Camp staff member and to attend all outings. *Additional release forms are included for each excursion in which Bound for Glory Camp hires a company.Date Of Signature*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920General Liability Waiver*I approve and give my permission for my child to participate in any classes or programs offered by Bound for Glory Camp. By registering for camp, I acknowledge that the activities carried on in the program carry certain risks for the participant. The parent/guardian has independently reviewed and evaluated the risks and determined to allow his/her child to engage in the program with full knowledge and acceptance of the risk. The registrant agrees to and hereby releases and forever discharges Bound for Glory Camp, their officers, employees, agents and volunteers from any and all liability for damages, loss or personal injury arising out of or related to camper’s participation in recreational programs. Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Media Release*Media Release I give my permission for pictures and/or videos to be taken my child and used for the publicity/marketing purposes of Bound for Glory Camp. In addition, I give my permission for the use of my child’s first name to be used for publicity/marketing purposes by Bound for Glory Camp. I waive any right to inspect or approve videos or photos. I waive all claims for compensation for photos or videos. Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Prayer Portfolio*Bound for Glory Camp receives funding from individual sponsors. Many of these sponsors would like to further support the Bound for Glory mission and the campers by praying for them and their experiences at camp. For parents and guardians who give permissions for sponsors to pray specifically for their child, we will send a brief portfolio of that camper to the sponsor. The portfolio will include a photo, first name only, grade, interest/hobbies and any parent/guardian prayer request. I give my permission for a prayer portfolio to be sent to a sponsor of Bound for Glory Camp. Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Christian Activity Acknowledgement*Christian Activity Acknowledgement Bound for Glory Camp is a Christian camp. We have daily musical-worship, prayer, and Bible devotions. Each are centered around understanding who Jesus is, his love for us, and how He brings hope and purpose to our lives. We are a non-denominational Christ-centered organization. Campers need not be of any religious affiliation or religious beliefs to attend camp. I give permission for my child participating in Christian, faith-based activities.Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Permission to Share Educational Information*I, the parent/guardian give my permission for my child’s educational information to be shared between Bound for Glory Camp, Augustine Literacy Project-Brevard, and my child’s school. Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Commitment Agreement*Bound for Glory Camp is a four-week camp. For campers to successfully make significant literacy gains, make achievements in enrichment classes, and build strong camp relationships, it is important that they attend each full day of camp As a nonprofit, we work very hard to raise more than $4,000 per camper to make Bound for Glory Camp a reality. It is important that the 15 spaces allotted for camp are filled with campers committed to attending each day of camp. We ask that you are your child make this commitment together. Please sign that you have read the above statement and will to the best of your ability make a reasonable commitment for your child to attend the full four weeks of Bound for Glory Camp. Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Camper's Signature*Please sign that you will to the best of your ability make a reasonable commitment to attend the full four weeks of Bound for Glory Camp. Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneThis field is for validation purposes and should be left unchanged.
