2023 WV(DOC) Youth Summer Camp Registration Form

Question Title

* 1. Camper Contact Information

Last Name

First Name

Congregation- (if FCC please list City)

Address

City/Town

State/Province

ZIP/Postal Code

Age

Email Address

Phone Number

Question Title

* 2. The camper is:

Male

Female

Question Title

* 3. The camper will be attending:

Kids Camp June 14th -16th (Designed for K-2 grades)

Junior Camp June 11th-16th (Designed for 3-5 grades)

Chi Rho Camp June 11th-16th (Designed for 6-8 grades)

CYF June 25th-July 1st (Designed for 9-12 grades)

Question Title

* 4. Grade Camper is currently enrolled in or will be completing May/June 2023

kindergarten

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Counselor

Question Title

* 5. Parent/Guardian Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 6. The camper has a history of infection of:

Nose

Throat

Ears

Sinus

Lungs

Other (please specify)

Question Title

* 7. The camper is currently in good health

Yes

No-But noncontagious

No-Currently Contagious

Please comment further if checkmarked “No”

Question Title

* 8. Does the camper have any conditions requiring restricted activity?

Yes

If “Yes” please explain further.

Question Title

* 9. Is appendix present?

Yes

Question Title

* 10. Camper is subject to:

Sleepwalking

Convulsions

Asthma

Fainting

Hernia

Skin rashes

Mood disorders

Hyperactivity

Attention Deficit

Further explanation:

Question Title

* 11. Camper suffers from the following allergies

Peanuts

Tree nuts

Gluten

Bee stings

Medications

Other foods

Other allergies described in comment field below:

Please describe reactions & treatments:

Question Title

* 12. Has the camper been exposed to acontagious disease recently?

Yes

If yes, please elaborate further.

Question Title

* 13. Camper is currently on the following medications:

Name, Dosage

Question Title

* 14. COVID vaccination status of camper

Unvaccinated

Vaccinated

If needs explanation, please provide here:

Question Title

* 15. Camper is up to date on all Public School Immunization Requirements

Yes

If no, please elaborate:

Question Title

* 16. Camper has received the flu vaccine in the past 6 months

Yes

Question Title

* 17. What is the camper’s swimming ability

Beginner

Intermediate

Advanced

Nonswimmer

Question Title

* 18. If you have a housing request, please provide the information here:

Question Title

* 19. Camper’s Family Doctor

Name

Phone Number

Question Title

* 20. Please provide 3 emergency contacts and phone numbers:

Name & Phone #

Question Title

* 21. In the event of illness or accident, I give permission to the Regional Minister/Camping Staff, and to the physician selected by the staff to secure proper treatment for, to hospitalize and to order, inject, anesthesia or surgery for the camper named above.

Yes

Question Title

* 22. Camper T-shirt Size

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XLarge

Adult XXlarge

Adult XXXlarge

AdultXXXXlarge

Question Title

* 23. The camper & Parent/Guardian agrees to this camp covenant: To come to camp expecting to grow in faith and in relationship with others, becoming a special part of the camp community. In order to do this, the camper covets to follow all the rules and guidelines set by the Christian Church Disciples of Christ in WV. The camper will attend and be attentive and participate fully. The camper will respect all present, cooperate with counselors, and take time to learn about God and share with their friends, family and church.

Yes

Question Title

* 24. The camp fee will be paid for by:

Me. Please use my email to invoice me to pay by credit card.

The church.

Cash/Check will be brought when arriving at the event.

Arrangements have been made through the regional ffice.

I am unsure. Please contact me to discuss arrangements.

Question Title

* 1. Camper Contact Information

Question Title

* 2. The camper is:

Question Title

* 3. The camper will be attending:

Question Title

* 4. Grade Camper is currently enrolled in or will be completing May/June 2023

Question Title

* 5. Parent/Guardian Information

Question Title

* 6. The camper has a history of infection of:

Question Title

* 7. The camper is currently in good health

Question Title

* 8. Does the camper have any conditions requiring restricted activity?

Question Title

* 9. Is appendix present?

Question Title

* 10. Camper is subject to:

Question Title

* 11. Camper suffers from the following allergies

Question Title

* 12. Has the camper been exposed to acontagious disease recently?

Question Title

* 13. Camper is currently on the following medications:

Question Title

* 14. COVID vaccination status of camper

Question Title

* 15. Camper is up to date on all Public School Immunization Requirements

Question Title

* 16. Camper has received the flu vaccine in the past 6 months

Question Title

* 17. What is the camper’s swimming ability

Question Title

* 18. If you have a housing request, please provide the information here:

Question Title

* 19. Camper’s Family Doctor

Question Title

* 20. Please provide 3 emergency contacts and phone numbers:

Question Title

* 21. In the event of illness or accident, I give permission to the Regional Minister/Camping Staff, and to the physician selected by the staff to secure proper treatment for, to hospitalize and to order, inject, anesthesia or surgery for the camper named above.

Question Title

* 22. Camper T-shirt Size

Question Title

Question Title

* 24. The camp fee will be paid for by:

Question Title

* 25. Additional information you would like us to know: