Rockford, IL Area Camp 2021
Lutheran Outdoor Ministries Center (LOMC) | Oregon, IL
Secure Online Event Registration
We're glad you're interested in Stroke Camp! Please fill out this registration form in its entirety and submit ASAP! Camp fills up fast and rooms are assigned on a first come, first served basis.
*Shirt sizes are not guaranteed for registrations received less than three weeks prior to camp!
Registration will be done individually, one person at a time. Once the first person has registered, you will have an opportunity to add a second person by entering their information and so forth. Registrants will be added by pressing the green "Add Registrant" button located right before the BILLING INFORMATION. (If there is a waitlist, that option will not be available and registrants will need to register separately.)
We are asking those who are NOT part of the Rockford, IL Support Group to please refrain from filling out a registration to allow members of the group to register first. If the camp is not filled by members by July 5, the camp will open to others. Please keep watching the www.strokecamp.org for updates on this situation.
In consideration of the health and safety for all of our participants:
You have attended Rockford, IL Area Stroke Camp before.
You have NOT attended Rockford, IL Area Stroke Camp before.
Minimum $50 (NONREFUNDABLE) per person deposit is requested with this registration. Remaining balance due one month prior to the retreat -refunds are made ONLY in the case of a MEDICAL emergency!
**Because of limited spots available, please keep additional attendees (anyone in addition to a survivor and caregiver) to a minimum.
Our best efforts will be made to accommodate your request , however if you are concerned about having food available that you can eat, we suggest bringing snacks and/or food to supplement your diet.
(**Your name, address, phone number, email address, and stroke date will be distributed to all in attendance at camp. All other information obtained for Stroke Camp is solely used in the event of a medical emergency and will be kept secured and confidential.)
For your convenience, we have included the health history form into this registration. You may fill it out now to save time later, print the PDF and fill it out and send it in to us (it will be included in the confirmation email), or fill it out at camp.If you are filling it out now, please complete ALL requested information. EACH CAMP PARTICIPANT is asked to complete a health history form. This does NOT need to be completed by a doctor!
The Health History Form is required for EACH camp participant (stroke survivors, caregivers, family members, and friends). All information being collected for the Stroke Retreat is solely to be used in the event of a medical emergency. All information will be kept secured during the event and after the event all forms will be destroyed.
I hereby authorize Retreat & Refresh Stroke Camp ("Camp") to use, publish, and/or disclose my Individual Identifiable Information ("Information") as described herein. This authorization is voluntary. No individual has coerced or forced me into signing this authorization. I am providing this authorization under my own free will. I am under no legal liability.
I understand that Camp may benefit, monetarily, non-monetarily, or otherwise, from the use of my own Information. I understand that I will not be entitled to any of said benefits and specifically release all claims to same. I understand that once Information is received by Camp, then it may be subject to re-disclosure and may no longer be protected by federal, state, or local laws. I waive any claims of violations of federal, state, or local laws which are the result of re-disclosure.
A. Individually Identifiable Information includes, but is not limited to:
B. Purpose of request:
C. Right to Revoke
I acknowledge that I have the right to revoke this authorization only in writing. Any revocation will be prospective and not retrospective.
By checking the box below, I acknowledge and affirm the statements in this authorization form.
This page is secured with 256 bit encryption