Clone of Summer 2025 Camper

2026 Summer Camper Registration

Crooked Creek Christian Camp - 2830 Coppock Rd Washington, Iowa July 13th-17th, Ages 12-18
We are so excited to have you join us in July for our 2026 Youth Summer Camp.

The camp will be July 13th-17th of 2026. We will begin check-in at Crooked Creek on Monday between 2-4 pm and will conclude camp on Friday at 12 pm.

This registration form will help us have all the needed information to prepare for an amazing camp together. You will be asked to complete your payment at the end of this form. Regular registration cost $385 until registration closes June 14th. Registration includes all lodging and meals for the weekend, swag and more.

We can't wait to meet all of our new friends at Midwest Messiah! Until then, if you have any questions, you are welcome to email us at MessiahMidwest@gmail.com.
Camper Information
Camper Name*

First NameLast Name
Camper Email*

Confirmation EmailPlease retype your email to confirm.
Camper Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Shirt Size (Adult Sizes)*

SmallMediumLargeXL2XL3XL4XL
Congregation/ Church
Parent/Guardian Information
Parent 1 Name*

First NameLast Name
Parent 1 Relationship*
Parent 1 Phone Number*

Area CodePhone Number
Parent 1 E-mail*

Confirmation EmailPlease retype your email to confirm.
**The above email that will be used to send out all camp information.
Parent 2 Name

First NameLast Name
Parent 2 Relationship
Parent 2 E-mail
example@example.com
Parent 2 Phone Number

Area CodePhone Number
Emergency Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
RELEASE, WAIVER, AND AUTHORIZATION FOR MEDICAL TREATMENT
I, (participant/parent/legal guardian if participant is under 18 years old) authorize my child to fully participate in the Midwest Messiah Summer Camp 2026 and related activities. I understand the activities are not without some inherent risk of injury.

In consideration of my child's right to participate in this activity, I agree to release, waive, discharge, agree not to sue, and to hold harmless for any and all purposes Midwest Messiah and their officers, employees, agents, and volunteers. I release Midwest Messiah from any and all liabilities, claims, or injuries, including death, that may be sustained while participating in this activity, including swimming, including traveling to, from, and for the activity, or while on premises owned or controlled by Midwest Messiah, including injuries sustained as a result of the negligence of Midwest Messiah. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of Midwest Messiah. I further agree to indemnify and hold harmless Midwest Messiah for any loss, liability, claim, or injury caused by me (my child) while participating in this activity, including traveling to, from, and for the activity, or while on premises owned, leased, rented, controlled, or operated by Midwest Messiah.

I also give my permission for me (my child) to receive any emergency medical treatment by a
healthcare professional, including emergency medical transportation, which may be required for injuries sustained by me (my child).

I agree to indemnify and hold harmless Midwest Messiah for any costs incurred to treat me (my child), even if a Midwest Messiah officer, employee, agent, or volunteer has signed hospital documentation promising to pay for the treatment.

Furthermore, I (my child) agree to follow all instructions and procedures in order to maintain a
maximum level of safety.
Participant's Name:*

First NameLast Name
Participant's Signature*

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Date*

MonthDayYear
Date
Parent Legal Guardian Name: (If Participant is under 18)

First NameLast Name
Parent/Legal Guardian Signature

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Date

MonthDayYear
Date
HEALTH STATEMENT
Check One*

YouthAdult
Event: Midwest Messiah Youth Summer Camp July 13-17, 2025

The proposed activity provided by Midwest Messiah requires participation in physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you and
cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart
related or other diseases. Therefore, all participants must be free of medical or physical
conditions which might create undue risks to themselves or any others who depend on them. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination.
Medical Info
Does the camper have any allergies, chronic illnesses, or medical conditions? If yes, please answer the next question.*

YesNo
List allergies, chronic illnesses, or medical conditions.
Does the camper use an inhaler or carry an epipen? If yes, please answer the next question*

YesNo
Please list inhalers used or needs of your epipen.
Dietary needs outside of a Biblically clean diet
Does the camper plan to bring medications to camp?*

YesNo
Health History

(Select the appropriate answer and explain any YES responses on the space provided below.)
Have you had or do you currently have any heart problems:*

YesNo
Do you frequently suffer from pains in your chest:*

YesNo
Do you often feel faint or have spells of severe dizziness:*

YesNo
Has a doctor ever told you that you have high blood pressure:*

YesNo
Are you a smoker:*

YesNo
Do you have arthritis, joint, or back problems :*

YesNo
Have you had any operations or serious injuries:*

YesNo
Do you have any chronic recurring illness or communicable diseases:*

YesNo
Are there any activities to be limited by a physician's advice:*

YesNo
Are you allergic to any medicines, insects, or pollens:*

YesNo
Do you have Epilepsy:*

YesNo
Do you have Diabetes:*

YesNo
Do you have any prescribed meal plan or dietary restrictions other than Biblically clean:*

YesNo
Please explain any yes answers.
Medication
Please check over the counter medications which camp personnel may administer as necessary:*

Acetaminophen (Tylenol)Ibuprofen (Motrin)Pepto BismolBenadrylCalamine/CaladrylImodium NeosporinNone
Are there prescribed medications currently being taken (please explain below)
Any other health related information.
Insurance Information
Do you carry family medical/hospital insurance?*

YesNo
Carrier:*
Policy Number*
Policy Holder*
Carrier Phone Number*
Representation & Agreement

By signing this form, you are agreeing to the below rules for this camp! Understanding that if the rules are broken, the directors of this camp have the right to ask the student to leave at the parent's expense. The parents will have to provide arrangements to pick the student up from camp at no refund. 2026 Rules- 1) Be Kind -treat others the way you would like to be treated. 2) Be in your room at designated times- girls are not allowed in boys rooms and boys are not allowed in girls rooms. 3) Stay with your Team Leader unless approved to not be with them. 4) No phones or electronics, MP3, cameras, ipod, (during camp). 5) Clothing must be modest (following the modest policy) or you will be asked to change. (No spandex- leggings unless they are use under other clothing). 6) During swimming everyone will wear short sand t-shirt (girls need to cover swimsuit). 7) No drugs, smoking, nicotine pouches, vaping or alcoholic beverages. 8) Respect camp property- leave things clean and in order. 9) No inappropriate language. (Staff reserves the right to define inappropriate language). 10) No one on one time along with the opposite gender (Rules of 3) 11) No one on one ministry. (Rules of 3) 12) Respect and listen to leaders 13) No camper may leave camp without a parent or guardian. You must let camp directors know if you must leave. 14) No swimming in the pond. 15) Only swimming during designated times. 16) If anyone has any Daily medication use, please communicate with the camp nurse. 17) All campers are expected to attend all scheduled events unless excused by the camp nurse or directors. 18) No Weapons, Knives or Fireworks. 19) No PDA (Public Display of affection). No Purple! 20) All Campers are expected to abide by all camp rules. If you do not conduct yourself in a proper manner, the directors reserve the right to send you home, with no refund.
Participant's Name*

First NameLast Name
Participant's Signiture*

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Date*

MonthDayYear
Date
Parent Legal Guardian Name: (If Participant is under 18)

First NameLast Name
Parent/Legal Guardian Signature

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Date

MonthDayYear
Date
Payment

(Return Policy) 1. A 90% refund may be given for any reason for a cancellation received 45 days or more prior to the event. 2. A 75% refund may be given for a cancellation received 31-44 days prior to the event, if after discussion and a majority of the board of directors feels it is a legitimate need.  3. No shows or cancellations within 30 days of event are not eligible for refunds, unless discussion and a majority of the board of directors feels it is a legitimate need. 
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Camper Registration $385.00

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Pay it Foward - Help A Student to come to Camp $385.00

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2026 Summer Camper Registration

Camper Information

Parent/Guardian Information

Emergency Information

RELEASE, WAIVER, AND AUTHORIZATION FOR MEDICAL TREATMENT

HEALTH STATEMENT

Medical Info

Health History

Medication

Insurance Information

Representation & Agreement

Payment