Path of Life Camp
53 Winn Hill Road
Port Crane, NY 13833

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Camp Registration Form

Name:__________________________ Gender: M / F Date of Birth: ___ /___ /_________
Parent/Guardian's name:____________________ Phone: (_____) _____ - _________   
Address:_____________________________________________________________________________
City:______________________________________ State:____ZIP:__________
Church:____________________________________
(optional)
Email:________________________
(optional)
Please select the weeks your child is planning to attend:
June 26–30Day Camp #1Western Week
July 3–7Day Camp #2Fiesta of Faith
July 9–15Teen CampRedneck Roundup
July 17–21Day Camp #3Astronaut Adventure
July 23–29Junior CampRedneck Roundup
July 31 – August 4Day Camp #4Arctic Summer
August 6–12Junior High CampCastle Conquest
August 14–18Day Camp #5Jungle Journey
Emergency Contact Numbers:
(optional) 
Mobile:(_____) _____ - _________
Work:(_____) _____ - _________
Other:(_____) _____ - _________
Medical Questionnaire:

Does your child have allergies to any medications? Yes / No
If yes, please explain:__________________________________________________________________________
Does your child have allergies to any food products? Yes / No
If yes, please explain:__________________________________________________________________________
Does your child have allergies to any environmental elements such as insect bites? Yes / No
If yes, please explain:__________________________________________________________________________
Does your child have any special needs we should know of to accommodate their stay with us? Yes / No
If yes, please explain:__________________________________________________________________________

If necessary, do we have permission to give your child:
MotrinYes / No
Oral
diphenhydramine
Yes / No
Topical
diphenhydramine
Yes / No
TylenolYes / No
Antibotic ointmentYes / No
Health Insurance Information:
Name of policy holder:____________________________________
Policy number:__________________________________________
Company:______________________________________________
If your child has medicine that must be administered during their stay with us, please fill out the medication form located at http://www.pathoflifecamp.org/medical.php 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 $50.00 must be received by the camp. This form must be postmarked by May 30, 2017 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.

Signature: __________________________________Date:___________________