CLW Application 2019
Please fill out ONE form for EACH applicant. Thank you!

We accept campers aged 9-15 and counselors aged 15-18. Counselors aged 15 are considered but may remain campers until age 16.

CAMP BEGINS at 6pm Sunday, July 28th. Campers should arrive in camp no later than 6:45. Please DO NOT ARRIVE in camp before 5:45 – staff will be eating their dinner!

For counselors, camp starts Sunday, July 28th at 11am.

CAMP ENDS 3pm Friday, August 2nd. Campers should be picked up no later than 3:45.

Email address *
Youth's First Name (and middle name if used): *
Your answer
Youth's Last Name: *
Your answer
Preferred name to go by at camp:
Your answer
For which role is your child applying? *
Will you be applying for financial aid for camp this year? *
Cost for one youth is $175
If the answer to the above question is yes, how much financial aid are you requesting?
Your answer
Youth's Age on July 1, 2018: *
We accept youth ages 9 and up.
Your answer
Youth's Preferred Gender: *
Youth's school grade in the Fall: *
Your answer
Youth's Date of Birth: *
Your answer
Youth's email address, if applicable:
Your answer
Youth's cell phone number, if applicable:
Your answer
Mailing address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Please choose a tee-shirt sizing option: *
T-shirt size *
Who will bring youth to camp (camp starts at 6:00 p.m. on Sunday, July 28)? Please provide the full name. *
Your answer
Who will take youth home from camp (camp ends at 3pm on Friday, August 2)? Please provide the full name. *
Your answer
Parent and Contact Information
Please fill out as much as is applicable
Home phone number: *
Your answer
Name of parent/legal guardian: *
Your answer
Parent/guardian cell phone: *
Your answer
Work phone number:
Your answer
Parent/guardian email address #1: *
Your answer
Name of second parent/legal guardian, if applicable:
Your answer
Parent/guardian #2 cell phone:
Your answer
Parent/guardian #2 work phone:
Your answer
Parent/guardian #2 email address:
Your answer
What year of Camp Living Waters will this be for your child? *
If you're new to Camp Living Waters, how did you hear about us?
If your child is new to CLW, would you like to request a tent partner?
Your answer
Hobbies and Interests
Tell us a bit about your child's interests!
What are your child's interests/hobbies? *
Your answer
My child's swimming skills are: *
Does your child attend a church? *
If you answered anything other than "no" in the above question, what church does your child attend, and in what city? (ex: Christ Church, Eureka)
Your answer
Does your child attend a religious youth group? *
If you answered anything other than "no" in the above question, what youth group does your child attend, and in what city?
Your answer
Health and Food Details
Please be as descriptive and detailed as possible. You may return to edit your answers later, if you would like.
What dietary needs does your child have? *
Please list any food allergies your child has: *
If none, put "N/A"
Your answer
Please list any medication allergies your child has: *
If none, put "N/A"
Your answer
Other allergies:
Your answer
Does your child have any medical concerns? *
(i.e. asthma) If none, put "N/A"
Your answer
Please list the medications your child is currently taking and instructions for dosage: *
If none, put "N/A." ALL prescription medication must be given to the Camp Medic upon arrival in camp.
Your answer
Date of last tetanus shot: *
Your answer
Has the youth been MMR vaccinated? (Measles, mumps, rubella). Please include the date if known.
If you have concerns about this question, please contact us at: CLWHumboldt@gmail.com.
Your answer
Date of last physical exam: *
Your answer
Child's Physician: *
Your answer
Physician's phone number: *
Your answer
Medical Insurance Provider: *
Your answer
Group ID Number: *
Your answer
Emergency contact name (not parents): *
Your answer
Emergency contact phone number(s) *
Please list as many as you are able
Your answer
Child's relationship to emergency contact: *
Your answer
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