Prairie Lakes District Church of the Nazarene Children’s Camp Health Record: Date of last Tetanus Shot: _____________________
June 18-22, 2012 Located at Crystal Springs Bible Camp Does the child have ____ or have had ______ (circle all that apply)
Those going in 2nd grade through 6th grade Heart Trouble Asthma Epilepsy Diabetes
Cost: $180 if postmarked by June 1 Allergies Other (please specify)
$200 if postmarked after June 1 Is the child presently taking medications? Yes (List below) No
Mail your registration and $50 non-refundable deposit to:
Kate Heyd at LaMoure Church of the Nazarene
520 1st Ave SE/LaMoure, ND 58458 Is there any additional health information that would assist us in
Make checks out to: Prairie Lakes SDMI providing better health care for your child? _____________________
Name: _________________________________ Gender: ________ Family Physician: _________________ Phone: ________________
Hospitalization Policy Name and Number: _____________________
Grade just completed: __________ Home church: ______________ _______________________________________________________
APPROVAL OF PARENTS OR GUARDIAN AND WAIVER CLAIM
Parent or Guardian: _______________________________________ THIS MUST BE SIGNED TO ATTEND!!!
I hereby approve the application, certify its correctness and expressly waive
Address: ________________________________________________ any and all claims against the Dakota District Church of the Nazarene, any of
its District Boards, and its representatives because of any injury or other
City: __________________ State:_____________ Zip: _________ damage that may be incurred to my child or his/her property in connection
with or incident to or travel to or from the Dakota District Church of the
Nazarene Summer Camp and related events in Crystal Springs, ND.
Home phone: ___________________ E-mail: __________________ Date: ___________________
Parent/ Guardian’s Signature: ______________________________________
Parent’s work/cell phone: Father:___________ Mother:__________
Your child is guaranteed to room with at least one person listed below.
IN CASE OF EMERGENCY CONTACT: _____________________
1st Choice: ______________________________________________
Emergency Phone: ________________________________________
Information you need to know!
IN CASE OF MEDICAL EMERGENCY- I understand that every effort will Registration is from 2-4pm. Before camp you will receive your child’s
be made to contact parents or guardian listed. In the event that I cannot be reached, I
hereby give permission to the physician selected by the staff to secure proper treatment cabin number in the mail. When you arrive, bring your child to the
for and to order any injections, hospitalization, anesthesia, or surgery for my child as cabin to meet his/her counselor. After dropping your child off, head to
named above. the cafeteria to officially register your child, leave medication and pay
the balance due.
Parent/Guardian’s Signature: All campers must be picked up from camp by 11:00am on Friday,
_______________________________________________________ June 22nd.
Items to pack: sleeping bag, pillow, toiletries, 1 piece bathing suit,
Many of the top bunks do NOT have railings. Initial here if you give sunscreen, bug spray, enough shorts & t-shirts for the week, 1 pair of
your child permission to sleep on a top bunk. ________ jeans, 1 sweatshirt or light jacket, and towels. PLEASE REMEMBER
A GREAT ATTITUDE, YOUR BIBLE & PEN!