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  Event Registration:  
  January 26-28 for 6-8th graders  
  February 23-25 for 9-12th graders  

  Student Information:  
  Name  
  Age  
  Sex Male Female  
  Home/Cell Phone  
  Address  
  City  
  State  
  Zip  
       
  Parent/Guardian Contact Information:  
  Parent/Guardian  
  Work Phone  
  Alternate Name  
  Alternate Phone  
  (alternate contact is used if parent can not be reached)
       
  Insurance Information:  
  Medical Insurance Company  
  Policy #  
  Family Dr.  
       
  I authorize the camp heath aid to treat my child as they determine is necessary for the time my child is at camp (ex: Tylenol). In case of an emergency, I understand that every effort will be made to contact me. In the event that I am not able to be reached I give permission to the physician chosen by the camp director, nurse, staff, etc. to secure any medical or emergency treatment deemed necessary. I also agree to absolve Ironwood Springs and its staff of any liability in case of injury to my son/daughter.

NOTE: Ironwood Does NOT provide medical insurance.		  
       
  Signature  
  Date  
       
  Payment / Contribution:  
  Card Holders Name  
  Credit Card Type Visa Mastercard  
  Card Number  
  Card Exp.  
       
  Email Address  
  Contribution (optional)  
  (This contribution will go to the general scholarship fund)  
     
 
This is my second (or more) registration.
Discount: $10-2nd child or more per family.
 
     
  Total Amount:  
 



 
 

It is our desire that no one be excluded from this Christian camp ministry. Please contact Ironwood for information on financial assistance.

1.888.533.4316 - or - 507.533.4315