Camper Information and Payment Options

Payment Options: You have the option of paying "in full" either by credit card (2.99% fee) or check.

If your church is paying a portion of the camper fee take a copy of your registration confirmation to the church and pay the church for your portion of the fee. The church is asked to make one check out to CCIW for payment of registration.

Billing information is required for all payment methods. Credit card information will not be collected unless that is your method of payment. Checks should be made out to CCIW and sent to CCIW, 401 W Jefferson St., Bloomington, Il 61701-3826.

Registration is not confirmed until payment is received.

I am Registering for

You & Me Child ( K-5th )
You & Me Adult

Payment Options

Credit Card (full payment) ($160.00)
Check (full payment) ($160.00)
Church Payment ($160.00)

Camper Name

Perferred name

Address

Phone Number

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Camper Email (if available)

Grade Last Completed

Date of Birth

Gender

Camper Pronouns

Church

Outdoor or Yurt Lodging: Check if interested.

Our default lodging for youth summer camps are in structures with plumbing, electricity, and AC. Should the option be offered, would your camper be interested in staying in a yurt or outdoor shelter (no plumbing or AC at the structure, but access to indoor restrooms/showers)? We do not guarantee this will be an option for every camp, but if it is for your camper, you will be contacted in advance so you can pack appropriate bedding.

Roommate Request

Directors will do their best to accommodate specific roommate requests; however, not all requests may be possible

List roommate(s):

Camp Walter Scott T-shirt

Each registered participant receives one t-shirt. Limit of 1 shirt per participant per season

T-shirt sizes:

Parent/Guardian(s) with Legal Custody

I am the legal guardian of the child(ren) with whom I will be attending camp.

If you checked the No box, provide the information below, including an emergency phone number and email addess for the primary parent/guardian.

Parent/Guardian 1 First & Last Name

Parent/Guardian 1 Address

Preferred Emergency Phone Number

Alternative Phone Number

Email: Updates about camp are sent via email. Please list an email that will be checked regularly.

Parent/Guardian 2 First and Last Name

Address

Preferred Phone Number

Parent/Guardian 2 Email

Other Emergency Contact: Someone not attending Camp

Emergency Contact Name

Preferred Emergency Phone Number

Relationship to Camper

Insurance Information

Insurance Card: The front and back of the card are required. You have the option to upload your insurance card OR fill in the information in the text box.

Uploading Insurance Card

Upload front of insurance card

Browse

Upload back of insurance card

Browse

Insurance Provider

Insurance ID

Policy Holder

Policy holder's relation to camper

Physican's Name

Physican's Phone Number

Camper Health Information

At Camp Walter Scott we recognize the diversity and variety in all of God’s people regarding their emotional, spiritual, physical, mental and nutritional health. The following questions are meant to help our staff be better prepared to ensure your camper’s needs are met as best as possible. It is our goal to provide the safest experience possible for all of our guests.

* Please indicate any food allergies or dietary restrictions that camp staff should be aware of. If your camper experiences any food-related behavioral concerns that you think would be helpful for our staff to know, please let us know here as well. Enter “NA” if not applicable.

Diet & Nutrition

*Please let us know of any social or mental health concerns that would be helpful for camp staff to know. Enter “NA” if not applicable.

Social & Mental Concerns

*Please let us know of any medical concerns that would be helpful for camp staff to know. Enter “NA” if not applicable.

Medical Concerns

*Please let us know of any prescriptions or medications, including over the counter, that your camper takes. All prescriptions and medications must be in original containers, including directions, dosage, and other necessary information. Prescriptions and medications must be handed over to camp staff during check-in and will be administered by an approved camp staff according to indicated prescriptions or instructions. Enter “NA” if not applicable.

Medications

* Please let us know of anything that would be helpful for our staff to know. Enter “NA” if not applicable.

Additional concerns, requests, comments

PERMISSIONS, AGREEMENTS, AND CONSENT

PERMISSION AND RELEASE FORM
I, parent/guardian of the youth camper(s) named in this registration form, grant permission for them to attend camp at Camp Walter Scott and do hereby release Camp Walter Scott (CWS) and the Christian Church in IL & WI (CCIW) from liability involving child/ren named in this registration form when participating and accompanying CWS and/or CCIW on activities inclusive to the camping program at CWS.

I grant the Sponsors, Ministers and /or Regional Representatives of CWS and CCIW the right, if necessary, to provide for emergency medical treatment of my child should such a need arise. Likewise, I release CWS and CCIW, sponsors and regional representatives from liability in the event of any accident related to this event and hold them harmless from damages.

I have read and agree to the permission and release form above.

TRANSPORTATION AND SWIMMING AUTHORIZATION

I, parent/guardian of the youth camper(s) in this registration form, grant permission and do hereby release CWS and CCIW from liability involving child/ren named in this registration form when participating and accompanying CWS and/or CCIW on activities such as swimming and/or transportation to and from a swimming location when available at Camp Walter Scott onsite or in Effingham. I release CWS and CCIW, Directors, Counselors and Regional Representatives from liability in the event of any accident related to this event and hold them harmless from damages.

I have read and agree to the permission and release form above.

MINOR MEDICAL AUTHORIZATION

Camp Walter Scott (CWS) and the Christian Church in IL & WI (CCIW) and their staff may give my child/ren Tylenol, Ibuprofen, Benadryl, and or a topical solution to treat them for minor aches, pains, and ailments as they become evident. The Camp Director, Nurse, or the Physician on call will administer all medications in accordance with the manufacturer's directions.

I have read and agree to the minor medical authorization form.

EMERGENCY MEDICAL AUTHORIZATION

I, parent/guardian of child/ren named in this registration form hereby authorize Camp Walter Scott and/or the Christian Church in IL & WI (CCIW) and their staff to seek and authorize emergency medical treatment for youth campers named in the registration form. This includes anesthetic, medical treatment, and the performance of whatever operations or removal of tissue decided to be necessary by the attending physician(s).

I have read and agree to the emergency medical authorization form.

WALTER SCOTT CAMPER PLEDGE

Camper: I agree to participate fully in the camp program, to cooperate with the camp leaders, and to attend the entire camp event. I will not bring firearms, knives, food, fireworks, electronic games, alcohol, drugs (except those listed under health information), or any other items that may be illegal or with the intent to cause danger to myself, those around me, or our surroundings. I will adhere to regulations regarding usage of cellphones and other electronic devices as implemented by camp staff. Furthermore, I understand that Camp Walter Scott and the Christian Church in IL & WI stand against bullying in every form and, therefore, I will treat others with respect and not engage or tolerate bullying. I understand that if I do not abide by this pledge, I may be sent home at my parents’ expense.

Parent/Guardian: I have discussed with my child/ren what is and what is not appropriate to bring to camp as well as discussed with them that bullying is inappropriate and will not be tolerated. I fully understand that should my child/ren commit a serious infraction of amp guidelines, I will arrange to remove my child from camp at the request of the camp director or regional staff.

Both parent/guardian and camper(s) have read and agree to the permission and release form above.

MEDIA RELEASE FORM

Camp Walter Scott (CWS), the Christian Church in IL & WI (CCIW), and their staff or designated agents may photograph or record activities, including campers, during the camping program.

I consent to the use of any video, images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of my child/ren during events at Camp Walter Scott to be used, distributed, or shown for promotional or other purposes.

I have read and agree to the media release form

Checking the consent boxes above represents your digital signature and authorization

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

Mobile Phone Number

You and Me

Camper Information and Payment Options

Roommate Request

Camp Walter Scott T-shirt

Parent/Guardian(s) with Legal Custody

Other Emergency Contact: Someone not attending Camp

Insurance Information

Camper Health Information

PERMISSIONS, AGREEMENTS, AND CONSENT

Billing Information