KK2012 Camper Registration by jianglifang


									    Date of Camp:

      SAT 7/28/12
                                            Camper Registration
         thru                                     Form
      WED 8/1/12
In order for your space to be reserved, a non-refundable/non-transferable deposit must be received by April 15, 2012. To be
eligible for a refund, minus your deposit, cancellations must be made no later than June 10, 2012. Please refer to the
Frequently Asked Questions Form for reservation procedures and policies. If you are registering as part of a group, you must
give your form to your Group Leader. If you are registering as an individual, please mail or drop off your form to Grace Christian
Church, Kid Nation. Incomplete forms will not be accepted and will be returned.
Camper Information:                This camper is registering              as an individual              with a church group

Camper FIRST Name                                                 Camper LAST Name

Street Address, City, State, Zip

Age (at time of Kids Kamp)                                        Birth Date (mm/dd/yy)

Gender:                    Boy                    Girl

T-Shirt Size: (please select one; price includes one t-shirt)
      YS                YM                 YL                AS                 AM                  AL                AXL

Cabin Mate
Camper would like to bunk with one of the following campers. (We cannot guarantee campers will be paired with their selection.
While we discourage this, if a Parent Counselor chooses to room with their child, this option will no longer be available.)

OPTION 1 – Friend’s FIRST Name and LAST Name                         OPTION 2 – Friend’s FIRST Name and LAST Name

Parent Information

Father’s FIRST Name and LAST Name                                    Mother’s FIRST Name and LAST Name

Primary Contact for Camper

Name of “Primary” Contact for Camper                                 Email Address

Primary Number: ____home ____cell ____other                          Secondary Number: ____home ____cell ____other

Secondary Emergency Contact
In case of an emergency, we will contact the parent or legal guardian immediately. If we are unable to reach them, please list a
secondary person we can call. This contact person must be someone not living in the same household.

Name of “Secondary” Emergency Contact for Camper                     Relationship

Day Phone: ____home ____cell ____other                               Evening Phone: ____home ____cell ____other

Kid Nation Kids Kamp – Camper Registration Form                                                                  Section F – 1 of 3
Camper FIRST Name                                                Camper LAST Name

Emergency Medical Information
Family Physician: ______________________________________                 Phone: ______________________________________

Do you carry family medical / hospital insurance?               YES             NO (If “No,” you must fill out a Medical Waiver)

Carrier Name: ________________________________________                   Phone: ______________________________________

Group Policy Number: __________________________________                  Name of Insured: ______________________________


Please check any medication(s) your child may be given by Kids Kamp Medical Personnel:

        Children’s Tylenol             Children’s Motrin                Benadryl 25mg               Pepto-Bismol / Tums

Medical Information
Please check “Yes” or “No” for each question. If “Yes” is checked, please give approximate date(s) of occurrence(s) and indicate
whether mild or severe.

MEDICATIONS                                                       ____     ____     Does this camper have any other medical
Yes     No                                                                          or non-medical conditions or diseases?
____    ____    Does this camper take any prescription                              __________________________________
                medicine(s)? If “yes,” please list (see
                medication policy): __________________            ALLERGIES
                __________________________________                Yes      No
                __________________________________                ____     ____     Does this camper have ANY known
                What is the reason for taking the above                             allergies? If “yes,” please list: _________
                medicine(s)? _______________________                                _________________________________
                __________________________________                                  _________________________________
____    ____    Is this camper allergic to any medicines?         ____     ____     Is there additional information regarding
                If “yes,” please list: __________________                           this camper’s health that we need to be
                __________________________________                                  made aware of? ____________________
MEDICAL CONDITIONS                                                                  __________________________________
Yes     No
                                                                  OTHER DETAILS
____    ____    Does this camper have asthma or other
                breathing problems? _________________             Yes      No
                __________________________________                ____     ____     Are immunizations current for this
____    ____    Has this camper ever had seizures? ____                             camper?
                _________________________________                                   Date of last tetanus shot: _____________
____    ____    Does this camper have diabetes? If “Yes,”         ____     ____     Is this camper mainstreamed in school?
                please list medications: ______________
                                                                  ____     ____     Does this camper have any difficulty with
                Testing supplies: ___________________
                Any hospitalizations? ________________
                                                                  Yes      No
                Acceptable Blood Sugar Range: _______                               Does this camper have any limitations that
                                                                  ____     ____
____    ____    Does this camper have a heart defect? __                            would affect their stay at camp? If “yes,”
                _________________________________                                   please list: _________________________
____    ____    Has this camper had any recent                                      __________________________________
                surgeries? _________________________                                __________________________________

Kid Nation Kids Kamp – Camper Registration Form                                                                  Section F – 2 of 3
Camper FIRST Name                                                  Camper LAST Name


Due to the challenging nature of activities at Kids Kamp, full disclosure concerning the camper’s medical history must be made.
If full disclosure is not made in advance, the Camp Director will be forced to refuse the camper, and the parents will be forced to
pick up the camper immediately. Campers who arrive with fever, ringworm, pink eye, lice, or any other communicable disease,
undisclosed handicap or disability will not be admitted. Please send any prescribed medications with your child, even if they do
not use them everyday. We are outdoors, often in the woods, and need to be prepared. All medications and supplies need to be
turned in upon arrival at Kids Kamp located at Camp Michindoh. NO child is allowed to share any medications. All medications
must be turned into Kids Kamp Medical Personnel. If your child keeps medication and shares it with another camper, they will be
sent home immediately without a refund. If your child contracts any contagious illness including but not limited to the following,
your child must be picked up (this is camp policy): Temp over 100, pink eye, uncontrollable vomiting or diarrhea, strep throat or
any other condition deemed serious by the staff.

The undersigned acknowledges that the health history is correct as far as they know, and the camper listed above has
permission to attend Kid Nation Kids Kamp, and to engage in all camp activities except as noted. The undersigned also
authorizes the executive staff or designated medical professionals to dispense over-the-counter medications as needed for the
camper listed above. By signing this form, the undersigned agrees to allow Kid Nation Kids Kamp, Camp Michindoh staff and
volunteers to share the camper’s medical history and any other pertinent information with health care providers as necessary.

The undersigned also consents to and authorizes the unrestricted use and reproduction by Kid Nation Kids Kamp and anyone
authorized by them, of any and all photographs and/or video images which may be taken of the camper listed above, for use
within the scope of Grace Christian Church, Kid Nation Ministries and Camp Michindoh.

Signature: ______________________________________________                                Date: ___________________

Certificate of Acknowledgement of Notary Public
Subscribed and sworn to before me this ____________ day of

______________________________________, Notary Public
___________________________________ County, Michigan
My Commission Expires: _____________________

Payment Information:           (please check one)

_____ CASH          _____ CHECK #__________               CREDIT CARD (choose one):         _____ MasterCard       _____ Visa
Credit Card Number:                                                                    Expiration Date:
AVS (3-4 digit number on back of card): __________                Authorized to Charge Deposit*:            Date: _____________
                                                                  Authorized to Charge Balance*:            Date: _____________
                                                                  Authorized to Charge Full Amount:         Date: _____________
Billing Address:
City, State, Zip:
Cardholder Signature:
*You can pay the full amount for Kids Kamp at one time. The deposit/full amount is due on or before April 15, 2012.

Kid Nation Kids Kamp – Camper Registration Form                                                                   Section F – 3 of 3

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