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2013 Camp Registration Form

*Required
Camper's Name:*
 
Camper's Birthdate:* (MMDDYYYY)
Address:*
City:*
State:*
ZIP code:*
Phone:* (2223334444)
Email:
Church:


Please select the weeks your child is planning to attend:*
Day Camp #1Egyptian Adventure
Day Camp #2Outback Adventure
Teen CampExtreme Teen Week
Day Camp #3Western Week
Junior CampCircus Week
Day Camp #4Farm Days
Junior High CampHorse Week
Day Camp #5Amazing Animals


Medical Questionnaire:
Does your child have any allergies to medications?*
If yes, please explain:
YesNo
Does your child have any allergies to food products?*
If yes, please explain:
YesNo
Does your child have any allergies to environmental elements such as insect bites?*
If yes, please explain:
YesNo
Does your child have any special needs we should
know of to accommodate their stay with us?*
If yes, please explain:
YesNo

If necessary, do we have your permission to give your child:*
•MotrinYesNo
•Pepto-BismolYesNo
•Topical BenadrylYesNo
•TylenolYesNo



Health Insurance:
Check this box if you would prefer to bring your child's insurance information to registration.
Name of health insurance policy holder:*
Insurance policy number:*
Company:*


Parent/guardian contact information
I can be reached at:
Cell: (2223334444)
Work:
Other:


If your child has medicine that must be administered during their stay with us,
please fill out the medication form located here and bring it to registration.


Medical Requirements: New York State law requires that we have information regarding
your child's immunizations. Please bring your child's immunization record when checking in
on the first day of camp. If you prefer, we will be happy to photocopy the record for you.

To receive the early registration discount and reserve your child's place:
The non-refundable resident camp registration fee of $40.00 must be received by the camp.
See here for mailing address. This form must be submitted by May 30, 2013 at 11:59pm to
receive the early registration discount.

In case of emergency: I understand every effort will be made to contact me. However,
if I cannot be reached, I give permission for the physician selected by the camp director
to secure proper medical treatment for my child.

By submitting this registration: I give my permission for the camp to use my child's
photograph in camp promotional information.