CAMPER application

Circle J Teen Ranch Camper Application

We are excited you have chosen to attend the first annual Circle J Teen Ranch! Please fill out the following information and prepare yourself for a once in a lifetime event.

  • Section 1: Teen 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 during camp if necessary (ie. Anti-biotic ointment, band-aids, Tylenol, Advil, Benedryl, 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.
  • This PIN will be used as part of the identification process for dismissal at the end of the day. Anyone who is authorized to pick your child up will need to know this PIN.
  • Please upload a valid ID of this person.
    Max. file size: 100 MB.
  • 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);



    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.
  • Type in today's date.
    MM slash DD slash YYYY

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