Camp Registration

Campers Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date*

Gender*

Desired Camp Dates*

Alternative Camp Dates

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Name of Parent or Legal Guardian*

First Last

Relationship To Camper*

Parent/Guardian Email*

Parent/Guardian Phone*

Parent/Guardian phone text capable?*

Yes
No

Emergency Contact Name if different from parent/guardian

First Last

Emergency Contact Phone

Emergency Contact relationship to camper

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Insurance Carrier*

Insurance Phone number*

Insurance Policy Holder Name*

Insurance Policy Number*

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Family Physician Name*

Family Physician phone number*

Date of last tetanus shot*

Activity Restrictions (or “none”)*

List Medical Allergies (or “none”)*

List Food Allergies (or “none”)*

List Other Allergies (or “none”)*

List Personal Medications (or “none”)*

Permission for Pain relievers*

Yes
No

Permission for Upper Respiratory/Allergy Meds*

Yes
No

Permission for Digestive Meds*

Yes
No

Permission for Topical meds*

Yes
No

Additional medical information

Additional personal information

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Questions/Comments

Terms and Agreements*

- View Terms and Agreements

I have read and agree to the Camper Agreement
I have read and agree to the above Permission Statement.
I have read and agree to the above Medical Release.
I have read and agree to the Consent to Use Photos and Videos.
I have read and agree to the above Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement.

Name of Parent or Legal Guardian

First Last

By Acknowledging all terms and agreements and stating name here.....

Comments

This field is for validation purposes and should be left unchanged.