Winter Retreat Registration Form 2011

2013 Winter Retreat Health Form
(this form must be completed and signed in order for your child to attend
and participate in activities at Pine Lake Camps)
Emergency Contact *cannot be same as parent/guardian listed Phone Number
Insurance Carrier
Name on Card
Policy Number
Health History (Circle all that apply; attach additional information if necessary)
Frequent Ear Infections
Bedwetting
Chicken Pox
Asthma
Downs Syndrome
Measles
Mononucleosis
Heart Defect/Disease
ADD/ADHD
Diabetes
Seizures
Tourettes Syndrome
Bleeding Disorder
Mumps
Current Medications:
Drug Allergies:
Additional Medical Information
If your child has any special needs, such as special diet, diabetes, asthma, physical and mental challenges,
autism, ADHD, behavior changes, etc., please enter them in the box below. Although we do have handicapped accessible facilities, be aware that Pine Lake Camps may not be equipped to handle children who require one-on-one attention or who have extreme special needs. If you have questions whether Pine Lake is the
right camp for your child, please call the camp office to discuss your situation with the director before registering your child for camp.
Medical/Activity Release
I Hereby:
1. Affirm there is no need of a doctor’s examination prior to camp based on good health history, or that such
an examination has been obtained and mailed to:Pine Lake Camps 32203 230th St. Eldora, IA 50627
2. Authorize Pine Lake Camps medical staff to dispense medications based on instructions provided.
3. Give permission to the medical personnel selected by the camp to order x-rays, routine tests, treatment, to
release my records if necessary for insurance purposes, and to provide or arrange necessary medical transportation for me or my child. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for
the person named below.
4. Understand that Pine Lake Camps reserves the right to dismiss any child whose action, behavior or attitude, in their judgement, is contrary to the best interests of camp.
5. Agree that any portraits or video of the camper taken at camp may be used by Pine Lake Camps or their
assigned agents for art, advertising or promotional literature. I waive my right to inspect or approve the finished product or copy.
Camper Name
Parent/Guardian
Parent/Guardian Signature
3
1
0
2
2013 pine lake camps
winter retreat - Speakers
Pastor Eric Weaver Sr. High Winter
Retreat I heard about Jesus 20 years ago at
Susan Lawrence Junior’s Winter Retreat
Susan is a Christian speaker, author and
storyteller. After a 33 year career as a teacher, she
hung up her chalkboard to pursue writing and
speaking fulltime. She has been the speaker for
women’s retreats, mother-daughter banquets,
mother-son outings, Sunday worship services,
children’s club programs, Sunday schools, youth
services, and missionary programs. Storytelling
and drama are intermingled with teaching in
presenting Biblical principles to her audience. She
often uses her certified therapy dog, Annie E, to tell the story of Annie’s
rescue.
Pastor Sam Schield Jr. High Winter Retreat Sam
graduated from Moody Bible Institute in May of 2012 and
has now been served at Faith Baptist Church in Washington
Iowa since the fall of 2012 as the Family Ministries Director.
He has a passion: "To see students become passionate,
unashamed and devoted to Christ, and each other while discovering their purpose and calling to make an eternal impact
in this world." He desires to see people be a light for Jesus in
their community and to spread the Gospel of Jesus Christ!
He is a cheese-head from Wausau, WI and loves camping
ministry and students!
Pine Lake Camps is a ministry of the Minnesota Iowa Baptist Conference. We
exist to provide a Christ-focused camp experience
that creates lifelong spiritual memories and friendships
camper information
Name
Birth Date
Street Address
Gender
City
State
Home Phone #
Cell Phone #
Zip
Email Address
Parent/Guardian
Phone Number
Second Parent
Phone Number
Home Church
Grade
I am coming with
my youth group. (If
you are coming
without your church
Pine Lake will
provide a counselor)
Coming as Staff for
youth group
(no charge)
Timeshare Camper *Check with your local church for cost and payment process
Choose your Winter Retreat:
January 18-20
Sr. High Retreat (9th - 12th Grade)
February 8-10
Jr. High Retreat (6th - 8th Grade)
January 25-27
Juniors Retreat (2nd - 5th Grade)
Non Timeshare
Cost:
$85
$85
$85
Roommate Request 1____________________________________
Roommate Request 2____________________________________
1.Fill out the registration and health form completely
2.Address envelope and send to Pine Lake Camps (address listed below)
3.Make sure to include full payment in envelope
Questions? Call or email us.
Pine Lake Camps
32203 230th Street
Eldora, IA 50627
Ph:641 858 3284 Fx: 641 858 2476
email:info@pinelakecamps.org
www.pinelakecamps.org
Register online at www.pinelakecamps.org
a Bible camp in Okoboji. Old became new
and my life has never been the same! God
has given me the privilege of sharing the
journey with my beautiful bride, Katie, for
over 15 years. We love dreaming and doing
music together, but our greatest joy is raising
our five children. Our home is bouncing with
life. I've been blessed to serve as a youth pastor and worship pastor at a few
different churches but now I have the joy of serving as the senior pastor at
First Baptist in Forest City... and I love it!
2013 Winter Retreat registration