CAMPER application

Circle J Kid’s Camp CAMPER Application

Please complete the entire form below. If you don’t have time to complete it all right now, you can click “Save and Continue Later” at the bottom of the form. 

  • Section 1: Child Information

  • If yes, please see a nurse upon arriving at camp!
  • I agree to allow over-the-counter medication to be administered to my child only by a registered Camp Nurse during camp if necessary (i.e. Anti-biotic ointment, band-aids, Tylenol, Advil, Benadryl, etc.).
  • Type in your name.
  • Section 2: Parent Information

  • Section 3: Emergency Contact Information

    Emergency contact must be someone not living in the same household.
  • Section 4: Authorized Pick-Up List

    Please tell us who has permission to pick up your child.
  • Section 5: Photo / Video Release Form

    Photographic, audio or video recordings may be used for ANY USE which may include but is not limited to:

    • Presentations;
    • Courses;
    • Online/Internet Videos;
    • Media;
    • News (Press);

    By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

    I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

    There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

    This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.

    By signing this release, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
  • Type in today's date.
    Date Format: MM slash DD slash YYYY
  • Section 6: Bus Rider Permission Form

    With your permission, Circle J Kid's Ranch would like to provide transportation for your child to swim at the YMCA located at 1375 N. Wellness Drive, Bloomington, IN 47404, on Friday, June 19, 2020.
  • Parent Guardian Statement:

  • Type in today's date.
    Date Format: MM slash DD slash YYYY
  • Section 7: Payment

    Congratulations! You have reached the end of the application. You will now need to pay camp fees to reserve a spot. Full payment is due by June 1st. If you have more than one child in the same family attending... please contact us for the discounted rates.

Even them will I bring to my holy mountain, and make them joyful in my House of Prayer: their burnt offerings and their sacrifices shall be accepted upon my altar; for my house shall be called a House of Prayer for all people.

Isaiah 56:7

Contact Us

4100 North Hartstrait Road
Bloomington, IN 47404
P: 812-876-9002
F: 812-876-8167