Date of Camp:
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
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
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: ______________________________
NOTE: YOU MUST INCLUDE A COPY OF YOUR INSURANCE CARD!!
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
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 __________________________________
____ ____ 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? ________________
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
THIS FOR M MUS T BE SIG NED BY THE PA RENT O R L EGAL GUARDIA N OF CA MP ER.
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: _____________
City, State, Zip:
*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