C
A M P C H A L L E N G E R
E G I S T R A T I O N 2
0 0 9
Camper’s First Name _____________________ Last Name _____________________________
Email Address (Parent): ___________________________________ Gender ________________
Age _______ Date of
Birth ______/______/______ Grade in Fall __________________
Address _____________________________ City ______________________ Zip
___________
Name of Church Regularly Attended _______________________________________________
Roommate Choice _____________________________________________________________
Mother’s Name ________________________ Day Phone _____________ Night ____________
Father’s Name ________________________Day Phone ______________Night
________ ___
If neither parent can be reached in an emergency, give alternate
name/phone #/relation to camper
______________________________________________________________________________________
Cost for each camp is $240.00. $40.00
non-refundable payment due with registration. Make checks payable to: Camp Challenge.
Mail to: Camp
Challenge, 610 Tierra St. Arroyo Grande, CA 93420
Camp Registering for (fill in one):
O
High School Camp (going into grades 9 – graduating seniors . . .
July 13 - 18
O
Junior High Camp (going into grades 7 – 9) . . . . . . . . . . .
. . . . . July 20 - 25
O
Junior Camp (going into grades 3 – 6) . . . . . . . . . . . . .
. . . . . . . . July 27 – August 1
Camp Challenge
Participation Release Agreement
While Camp Challenge
makes every effort to provide a safe and pleasant environment for your child, we do require that this participation agreement
be read, filled out, signed and dated by the parent or legal guardian of each child under 18 years of age who wishes to participate
in the activities which occur at Camp Challenge.
I, the parent/guardian of _____________________________________(referred
to in this release as “the camper”):
a) hereby authorize the administration of any medical attention deemed necessary by the Camp
Challenge certified First Aider, and/or any licensed physician during the dates of camp indicated on this form.
b)
hereby authorize the transportation of this
camper to a licensed medical facility for attention as needed.
c) hereby confirm/report that this camper has been immunized in accordance
with the requirements for admission to school set by the California State Board of Education.
d)
hereby give permission for my dependant to attend
camp and participate in all camp activities and events. I understand that all
recreational activities and attending camp in general, have the inherent possibility of death or injury to person or property,
which may result from participating in and/or observing such activities. Death,
personal injury and/or property damage may also result from activities which we do not allow and may result from participating
in or observing activities which are prohibited. I understand that this Title
of Release constitutes a full and complete release from liability insofar as Camp
Challenge is concerned and the camp staff, of responsibility for any
and all injury or damage to my child.
e)
hereby give permission to Camp Challenge to photograph and/or video tape
my child for use in future print, video, and/or web applications.
Parent or Guardian Signature ______________________________________ Date ___________
A receipt of payment and information letter will be sent
to each camper after receiving the completed registration and health history forms.
Be sure to fill out both sides of this registration form.
CAMP CHALLENGE
MEDICAL FORM
Due to new California state regulations, we
are required to collect the medical records below on all campers. Please note, shots do not need to be up to date, we
simply need to know when they were last administered. Please write "N/A" if tests have never been administered.
HEALTH HISTORY
HEALTH SUMMARY
Vaccines
Date of Last Immunization Write "NONE"
if not applicable
DPT/TD/Tetanus __________________ Any current health conditions that require medication,
treatment, or special restrictions while at camp.
Polio
__________________
Measles (MMR) __________________
Any
medical treatments relevant to participating at camp?
Tuberculin Test __________________
Flu __________________
Other (Specify): __________________
Any allergy or dietary restrictions?
MEDICAL INFORMATION
Medical
Insurance: _______________________ Any activity restrictions while
at camp?
Policy # : ______________________________
Doctor: ________________________________
Any mental conditions that require medication or
Doctor's Phone: _________________________ attention?
Date of
last medical exam: ________________
OVER
THE COUNTER MEDICATION List any prescribed medications
taken while at camp.
Fill in YES or NO
for each medication you
authorize the
camp to administer.
YES NO
YES NO
O
O Pepto-Bismol O O Tylenol ALL
MEDICATIONS and PRESCRIPTIONS MUST:
1. Be in the original container
O O Tums
O O Benadryl
2. Have a note with HOW, WHEN, and WHY to
administer which is SIGNED by the legal guardian
O O Cough Drops O
O Neosporin 3. Bring only the
amount needed for the week at camp
O O
Advil O O
Cortisone Please fill out ALL medical fields. If they are not
filled
.5% cream out, camper will not be able to attend according to
new Government Standards.
Office use only: Date # Amt paid Amt due
