REGISTER

Submit Online Form or

DownLoad Printable Form Here!

CAMPER'S REGISTRATION INFORMATION

Today's Date Enter Today's Date

Adult T-shirt Size:

Required

XXL

XXXL

Camper's Name: Enter Name

Required

Date of Birth

Required

Enter DOB

Age: Enter Age

Male

Female

Home Address: Enter Address

Required

City:

Required

Enter City

State:

Required

Enter State

Zip code:

Required

Enter Zip

Email:

Required

Enter Email

Phone Number:

Required

Enter Phone Number

First Name:

Required

Enter Name

Middle Initial:

Required

Last Name:

Required

Enter Last Name:

Address:

Required

Enter Address

Phone Number:

Required

Enter Phone Number

Alternate Phone:

Required

Enter Alternate

Email Address:

Required

Enter Email

Emergency Contact Information:

Required

Contact 1 Name

Relation to Youth:

Required

Phone Number:

Required

Enter Text

Required

Contact 2 Name

Relation to Youth:

Required

Phone Number: Contact 2 Phone

Required

Has there been any recent exposure to a contagious disease?

Yes

If so, what and when?

Required

Enter Your Message

Is child subject to constipation?

Yes

Convulsions or seizures?

Yes

Any Allergies?

Yes

Frequent use of laxatives?

Yes

Is the child a sleepwalker?

Yes

Is the child subject to fainting?

Yes

My child has permission to participate in the following: pictures, cookouts, hiking, swimming, roller-skating, bowling, recreational activities, and park experiences:

Yes

State of child's last illness:

Required

Enter Text

Is your child taking any medications presently?

Yes

Required

If so, What?

Enter Meds

Date of Last Tetanus shot:

Required

Enter Date

Does your child have special dietary needs?

Yes

If yes, what?

Vegetarian

Other

If other, please explain:

Required

Enter Text

Known food allergies:

Required

Enter Text

Parent/Guardian Signature:

Required

Enter Signature

Permission to treat in case of emergency:

Yes

(Please initial)

Enter Text

Required

Insurance Company:

Enter Text

Required

Policy/Agreement Number:

Required

Enter Text

Family Physician:

Required

Enter Name

Office Number:

Required

Enter Phone Number

Permission to photograph or video your camper and utilize for advertising (i.e. website, social media, videos, etc.):

Yes

Anything else we need to know about your child: Enter Your Message

Required

Submitting Form...

The server encountered an error.

Form received.

PARENT & EMERGENCY INFORMATION

Camper Fees Before June 30th
# of Children                 Total Owed
1                                       $300
2                                       $600
3                                       $900
4                                       $1200
Camper Fees After June 30th
# of Children                 Total Owed
1                                       $325
2                                       $617
3                                       $909
4                                       $1287

MEDICAL INFORMATION *VERY IMPORTANT*

pay online here:

*Note to Parents Regarding Medication:

Campers will NOT be allowed to keep medication with them at any time, including Over-the-Counter medication. All medication is to be in its original bottle or box, with your child's name on the container. Please have Epipen prescription with child's name on the medication. All medication including inhalers, pain relievers, and allergy should be given to the camp nurse upon arrival.

stay connected with us:

site design by Steps Above Design