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* 1. Camper Contact Information

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* 2. The camper is:

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* 3. Grade Camper is currently enrolled in:

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* 4. Parent/Guardian Information

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

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* 6. The camper is currently in good health

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

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* 8. Is appendix present?

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* 9. Camper is subject to:

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* 10. Camper suffers from the following allergies

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* 11. Has the camper been exposed to  acontagious deisease in the last 2 weeks?

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* 12. Camper is currently on the following medications:

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

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

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* 15. What is the camper’s swimming ability

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* 16. Camper’s Family Doctor

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

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* 18. 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.

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* 19. Camper T-shirt Size

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* 20. 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.

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* 21. The Midwinter fee will be paid for by:

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