LSBC 2018: Illuminate - Senior High Camp

Camper Name *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Camper Age *

Grade just completed *

Gender *

Male Female

Birth Date *

Month Day Year

Parent/Legal Guardian *

Relation *

Address (if different from camper)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone *

Area Code Phone Number

Alternate Phone

Area Code Phone Number

Emergency Contact Name(if parent or guardian is not avaliable) *

Emergency Number *

Area Code Phone Number

Roommate #1

Roommate #2

How did you hear about LSBC?

Are you a first time camper? *

Yes No

I agree that photos taken at camp which may include my child can be used for publicity and on social media *

yes no

Name of Church *

Church Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please note: LSBC will only bill churches with which we have a prior established payment arrangement. If you are unsure if your church has a payment arrangement with us, please make full payment in advance or choose "other" and we will contact you to discuss payment. All fees or partial fees being paid by parents/guardians must be paid no later than check-in day.

Method of payment *

Full payment / credit or debit in advance Full payment / check, cash or card on check-in day Partial Payment / credit or debit in advance, bill church remainder Partial Payment / check, cash or card on check-in day, bill church remainder Bill entire fee to church

Coupon code

Parents Email (camper confirmation will be sent by email, if left blank no confirmation will be sent)

By entering your initials and pressing submit, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, you give consent for medical treatment for the above named camper by authorized personnel. You understand that the above named camper will only be released to the names listed above; an update to these names may be made at check-in. You certify that your child has my permission to attend camp and participate in all activites. Further, I understand that the entrance to Lake Springfield Baptist Camp, 5878 Iron Bridge Road, Chatham, Illinois, is an easement granted to us by neighboring landowners. As such, those landowners have established a speed limit of 10 miles per hour on the lane to the camp. Additionally, the landowners have erected speed bumps and placed other traffic control devices on the lane. By initialing below, I also acknowledge that I am aware of the speed limit and traffic control devices and will comply with such directives when entering and exiting the camp. In the event my child is dropped off or picked up by someone else, I agree to make that person(s) aware of the speed limit.

Electronic signature, please initial *

LSBC 2019: Jesus Saves - Day Camp #2

Camper's Information

Parent or Legal Guardian Information

Emergency Contact Info

Roommate Request

Other Information

Camper Photo Release

Church Information

Payment Information

Confirmation