CAMPER INFORMATION  Complete all fields below.  A separate form is needed for each camper.

Select Session Your Camper Will Attend:       ⃝    Primary Camp: June 24-26             ⃝ Elementary Camp: July 29-31

Name:  

Address:                                                                              City & Zip

Nickname:

Birthdate:        

Age

T-shirt size   Youth: XS, S, M, L, XL

                      Adult: S, M, L, XL

Shoe Size

Grade (2022-2023 School Year)

School:

Local Church (if applicable)

Pastor (if applicable)

Pastor’s E-mail (if applicable)

What are camper’s favorite activities?

Has camper participated in overnight camp before?  □Yes   □No  

If so, where?

What type of support (if any) will your camper need with self-care routines (bath, getting to bed, getting up and dressed, keeping up with belongings)?

Does your child swim?   □  yes      □ no                            Rate their swimming ability:     □ good  □ fair        □poor

Does your child have any medical, physical, or emotional needs that will make participation in camp activities more difficult?

□Yes    □No     If yes, please describe their special challenges:

Is there any other information you want us to know about your camper?

PARENT/LEGAL GUARDIAN INFORMATION   Complete all fields below. Legal documentation is required at registration and does not stay on file for Legal Guardians.

Relationship to Camper:  □Parent  □Step-Parent   □Legal Guardian (Legal Documentation Required)

Name

Address                                                                                

City & Zip

E-Mail (required)

Primary Phone                                               □Home    □Cell

Secondary Phone                                                □Work   □Cell

Relationship to Camper:  □Parent  □Step-Parent   □Legal Guardian (Legal Documentation Required)

Name

Address

City & Zip

E-Mail (required)

Primary Phone                                           □Home    □Cell                        

Secondary Phone                                               □Work   □Cell                  

EMERGENCY CONTACT

Provide contact information for adult(s) other than the parent/legal guardian above in case parent cannot be reached

Name

Address    

City & Zip

E-mail

Relationship to Camper

Primary Phone                              □Home  □Cell

Secondary Phone                                                    □Work  □Cell

HEALTH  INFORMATION

Check if camper has had any of the following:

__ Lung Trouble   __ Asthma               __ Tonsillitis  

__ Appendicitis    __ Heart Trouble    __ Diabetes    

__ Hay Fever        __ ADHD                  

__ Ear Trouble     __ Sinusitis        

Will camper require medication to be administered during camp?  

□No      □Yes

Please List:  _______________________________                                   ___                          Medication form(s) required.  All medications must be left with director to dispense and must be in original container with original label and instructions.

Allergies (Bee stings, medications, poison ivy, etc.): 

Epi-Pen Required   □No   □Yes     Allergy Action Plan from physician required          

Food Allergies or Special Dietary Needs:

Epi-Pen Required?   □No   □Yes     Allergy Action Plan from physician required           

Physician’s Name                                                                          

Phone:

Emergency Phone:

Medical Insurance Company

Pre-Admission Phone Number

(if applicable)

Insurance Policy Number/Member ID

Copy of both sides of card must accompany this application.

Group Number (if applicable)

Parent/Guardian Consents and Releases

Conduct Code:  Camper (child) should adhere to all camp rules and policies.  Any camper who violates camp rules or is disruptive or uncooperative with the camp program or others in attendance is subject to dismissal and forfeiture of fees.

General and Emergency Medical Authorizations: I hereby give permission to the first aid personnel selected by camp personnel to determine and provide standard first aid care and administer medications sent for camper and over the counter medications; and in an emergency case to determine and select outside medical personnel and facilities.

I grant permission to such to order x-rays, make routine tests, hospitalize, secure proper treatment for and order injection and /or anesthesia and/or surgery for this camper.

Camper has my permission to attend SELAH Children’s Camp and engage in all activities except as noted below

The information recorded on this form is accurate and complete.

Signature of Parent/Guardian                                        

Date:                

Notary Signature and Seal: