2012 Summer Camp Registration/Health Form
Last Name ______________________________________ First Name _________________________________ Boy _____ Girl ______
Address ______________________________________ City ___________________________________ St ____________ Zip ________
Day phone ________________________ Night Phone ________________________ Emergency Contact # _______________________
Mother Name ______________________ Phone ______________ Father Name _______________________Phone _______________
Grade Completed ____________________ Age __________________ Date of birth __________________
Home church ______________________________________________ City ______________________________________ St _________
Cabin Mate requested 1st choice _____________________________________ 2nd choice __________________________________
Camp Week mark below
Date Grade Compl. Rate Team Timothy ages 15 - 17 Rate
___ #1 wk PPCJune 10 - 15 3rd - 11th $295.00 ___ Session #1 June 10 -22 $240.00
___ #2 wk PPCJune 17 - 223rd - 11th$295.00 ___ Session #2 June 24 to July 6 $240.00
___ #3 wk Blast June 24 - 29 6nd -11th $325.00 ___ Session #3 July 8 - 20 $240.00
___ #4 wk Freedom July 1 - 6 3rd - 11nd$195.00 For a one week option contact Camp
___ #5 wk Mini July 8- 10 K - 2nd $150.00 Team Timothy must be paid in full when reservation
___ #6 wk PPCJuly 15 - 203th - 11th $295.00
(PPC refers to Pal, Pioneer, Crusader age groupings) Free "T" shirt size Child Med __ Large __
Adult sm __ med __ lg __ xl __ xxl ___
A deposit of $125.00 is required
Money Matters
Deposit $ ________ Total check sent $ ________ Credit card charge $ _______ MC ___ Visa___ Disc ____
Spending $ ________ Number ______ - ______ - ______ - ______ sec # __ __ __
Survival Kit $ ________ Signed ________________________________ exp. date ___ ___
Gift To Camp $ ___________
Total $ _______________ Personal Insurance Information
Insurance Company _______________________ Phone # _________________
Policy # ______________ Group ___________ Policy Holder _______________
In the event of illness, the parent/guardian are completely responsible for any necessary treatment cost incurred.
Camp Michawana holds a secondar coverage status.
Health Information
It is OK to give my child over-the-counter medications if needed. ___ Yes ___ No
Immunization Record: State law requires that all immunizations to be up to date Please insert dates.
Tetanus/Diphtheria ____________ Polio ________________ Measles __________ Mumps __________ Rubella _________________ Chicken Pox _____________ Other _____________
Health History Please check if any apply
Convulsions ____ Rheumatic Fever ____ Asthma ___ Diabetes ___ Epilepsy ___ Other _________________________
Allergies to Aspirin ___ Penicillin ___ Other drugs: List ___________________________ Food List ____________________________
Insect bites ____________________ Concerns/Special Health/Behavior Needs ______________________________________________
Has this child been exposed to, or do you currently have any contagious diseases? ______________________
Medications All medications must be in original prescription container with name, medication, strength & dosing
Medication Purpose Dosage _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Camper Release
Parents or guardians will be notified if their child receives treatments for an injury/illness that requires a physician. I understand that there may be elements of risk associated with activities at camp. I hereby give permission to the physician selected by Camp Michawana to give emergency medical or surgical treatment and other non-surgical medical care. I give permission for my child to participate in all activities at camp and hereby release an agree to indemnify and hold harmless Camp Michawana and its trustees, officers, employees, agents, and volunteers from any and all claims arising from such participation. In signing this document, I hereby certify that the above information is correct.
___________________________________________________________________ Date ________
Signature Parent or guardian is required
Upon receipt of completed forms and deposit you will receive confirmation with all necessary information for participation.
