kids camp reg form

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					     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: ________________________________________
                                                                                           2nd Choice:______________________________________________
                                                                                                                  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!

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