FUMC Mobile Day Camp Registration
Event Timing: June 11-15
Event Address: 400 W. 7th Ave., Stillwater, OK, 74074
Contact us at cward@fumcstw.org
Email address *
Child's Name *
Your answer
Birthday *
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Grade *
Your answer
Gender *
Required
Home Church
Your answer
Does this camper qualify for free/ reduced price lunch? *
Required
Race/Ethnicity *
Required
I consent to the use of this camper's image or voice in photographs, audio and/or video recording taken during the course of this camp for the purpose of publicizing the camping program of the Oklahoma Conference of the United Methodist Church. *
Required
Parent/Guardian Name consenting to the question above. *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Emergency Contact *
Your answer
Relationship to Camper *
Your answer
Phone *
Your answer
Does your child have any food, drug, environmental, or other allergies? *
Required
If so, please explain:
Your answer
Dietary restrictions *
If so, please explain:
Your answer
Will your child be taking any medications while at camp? *
Required
If so, please explain:
Your answer
Has your child ever been hospitalized or had a serious injury? *
Required
If so, please explain:
Your answer
Does your child have any restrictions on activity? *
Required
If so, please explain:
Your answer
Has your child experienced, or is currently experiencing, any of the following conditions? *
Required
*
Required
Family Doctor *
Your answer
Phone for Family Doctor *
Your answer
Do you have health insurance? *
Required
Name of Policy Holder
Your answer
Policy Holder Phone Number
Your answer
Employer Name (if insured through company)
Your answer
Company Plan & Name
Your answer
Insurance Company Phone Number
Your answer
Policy Number
Your answer
Group Name/Number
Your answer
Would the camper need financial aid to attend the mobile day camp? *
Required
I, the undersigned, hereby acknowledge that certain risks of injury are inherent to any camp’s program, including but not limited to participation in recreational activities, a child’s failure to follow instructions of supervisors, communicable illness, and independent acts of third parties not under the control of supervisors. I acknowledge that all risks cannot be prevented, and assume those beyond the control of the Oklahoma United Methodist Camps staff. These types of injuries may be minor or serious and may result from one’s actions, or the actions or inactions of others or a combination of both. I will take responsibility to see that my child is prepared for all activities and is in good health each day of the session. I hereby assume all risks associated with participation in the Voyage Mobile Day Camp programs and agree to hold harmless Oklahoma United Methodist Camps, its directors, officers, employees, volunteers, et al from and against any and all claims, demands, losses or liability of any kind or nature which may arise in connection with injuries suffered to my child while enrolled/participating in their program. In case of medical emergency, I understand that every reasonable attempt will be made to contact me or the emergency contact named below. However, in the event that I or my named contacts cannot be reached, I give my permission to the adults in charge of the programs to secure and receive emergency medical or first aid treatment for my child, including transport via ambulance to a hospital if necessary. I consent to the sharing and release of any medical information listed above with the appropriate staff members of the program and/or medical personnel that may be necessary to ensure the safety and wellbeing of my child. I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance. I have read and understand the above informed consent agreement in its entirety and hereby give my consent for my child to participate knowing all of the foregoing. *
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Parent/Guardian Name *
Your answer
A copy of your responses will be emailed to the address you provided.
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