Camp Marengo Registration Form 2013, page 1 of 2 Personal Information
|
|  Yüklə 43 Kb.
|
| Camp Marengo Registration Form 2013, page 1 of 2
Personal Information: Camper Name: _________________________________________________________ □ Male □ Female Date of Birth: ______________________________ Age: ________ Grade (Fall 2013): _________ Mother’s Name: _________________________________ Father’s Name: _________________________________ Street Address: _______________________________________________ City: _____________________________ State: ______________ Zip: ____________ Home Phone: (______) _____________________ Mother’s Work Phone: (______) __________________ Father’s Work Phone: (______) __________________ Cell Phone: (______) ______________________ Email: ___________________________________________ Camp Attending: Please check the appropriate box to indicate which week of camp your child will be attending. Campers may choose any camp for the school grade they will be completing or going into in the Fall of 2013. □ June 9-14, 2013 Junior High Camp (grades 7-9) $180.00 □ July 5-6, 2013 Family Camp $30 per person □ June 16-22, 2013 Senior High Camp (grades 10-12) $213.00 □ July 7-10, 2013 3rd thru 5th Grade Half Week $130.00 □ June 23-28, 2013 6th thru 8th Grade Camp $180.00 □ July 7-12, 2013 3rd thru 5th Grade Full Week $180.00 □ June 30-July 5, 2013 4th thru 6th Grade Camp $180.00 □ July 7-13, 2013 Performing Arts Camp (grades 9-12) □ June 30-July 5, 2013 Paintball Camp (grades 9-12) $250.00 $223.00
T-Shirt Size: Adult □ Small □ Medium □ Large □ X-large □ XXL Child □ Small □ Medium □ Large Church Information: Name of Church Camper Attends: ______________________________________________________________ Street Address: _____________________________________________ City: ___________________________ State: ______________ Zip: ____________ Church Phone: (______) _____________________ Pastor’s Name: _______________________________________
If out of town during camp, phone number to reach parents: (______) _____________________________ Please list another contact in the event of an emergency and the parent/guardian cannot be reached: Name: ________________________________________ Relationship to camper: ________________________ Home Phone: (______) __________________ Work Phone: (______) __________________
Please indicate who will be picking up your camper. *Please note - your child will only be released to whoever is indicated on this form or presents the pick-up card. ________________________________________________________ Medical Information: Family Doctor: ___________________________________________ Phone Number: (_____) _____________________ Health Insurance Company: ___________________________________________________________________________ Primary Holder: __________________________________________ Policy Number: ____________________________ *Please attach a copy of your child’s insurance card to this registration M
edication being taken by camper (must be in original container): __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please note: Our First Aid Staff cannot administer prescription medications without the written permission of parents, guardians or physician. Please indicate name of medication, dosage, frequency, the time given including any other information necessary. Allergies (please check all that apply): □ Bee Stings □ Food ____________________ □ Medication ____________________ □ Other ____________________ Is your child subject to any of the following (please check all that apply)? □ Fainting □ Sleepwalking □ Epileptic Seizures □ Convulsive Seizures What was the date of your child’s last Tetanus shot? ____________________________ Any other important medical information: __________________________________________________________________________________________________
___________ Parent/Guardian Initials □ Antibiotic Ointment (for scrape, cut, splinter) Consent and Liability Release: Special activities are offered each week of camp. Please check the activities in which you give consent for your child to participate. □ Climbing Wall (all ages) □ Archery (not offered 3rd to 5th Grade Week) □ High Ropes (first 3 weeks of camp) □ Tag Ball (first 3 weeks of camp) □ Paintball* (first 3 weeks of camp) ________ Parent/Guardian Initials *Please fill out the additional release form for your child to participate in Paintball. I give consent for the above named camper to engage in the activities of Camp Marengo. Included in those activities are (not limited to): swimming, climbing wall, ropes course, play areas, and obstacle course events. During the camping season pictures and video are taken of campers and activities. These photos and/or video may be used for future promotional use. I will not hold Camp Marengo Ohio Retreat Center, Ohio Ministries of the Church of God, Camp Staff or any other individual responsible for injuries incurred while participating in Camp Marengo’s camping Program. In case of medical and/or surgical emergency, I hereby give permission to the selected physician by the Camp Director to hospitalize, secure proper treatment for, and order injection, anesthesia, X-rays, or surgery for my child as named above. I also give permission for the First Aid Staff to administer the medications indicated on this form. My signature below is evidence of my understanding of all above information. _______________________________________________________________________ ____________________________ Parent/Guardian Signature Date Payment and Registration Fee: A minimum of $50.00, non-refundable deposit is required to register your camper. Please send a check or money order along with this form made payable to “Ohio Ministries”. The balance is due the first day of camp. Please send registration to: Melyssa Trussel Registration for the first 3 weeks of camp must be postmarked by May 20 P.O. Box 177 and registration for the last 2 weeks of camps must be postmarked by June 10. Marengo, Ohio 43334 Registration postmarked after those dates will be assessed a $20 late fee. |