Midwinter Registration 2020 Question Title * 1. Camper Contact Information Name Congregation Address Address 2 City/Town State/Province ZIP/Postal Code Age Email Address Phone Number OK Question Title * 2. The camper is: Male Female OK Question Title * 3. Grade Camper is currently enrolled in: 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th College Counselor OK Question Title * 4. Parent/Guardian Information Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number OK Question Title * 5. The camper has a history of infection of: Nose Throat Ears Sinus Lungs Other (please specify) OK Question Title * 6. The camper is currently in good health Yes No-But noncontagious No-Currently Contagious Please comment further if checkmarked “No” OK Question Title * 7. Does the camper have any conditions requiring restricted activity? Yes No If “Yes” please explain further. OK Question Title * 8. Is appendix present? Yes No OK Question Title * 9. Camper is subject to: Sleepwalking Convulsions Asthma Fainting Hernia Skin rashes Mood disorders Hyperactivity Attention Deficit Further explanation: OK Question Title * 10. 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: OK Question Title * 11. Has the camper been exposed to a contagious disease recently? Yes No If yes, please elaborate further. OK Question Title * 12. Camper is currently on the following medications: Name, Dosage Name, Dosage Name, Dosage Name, Dosage Name, Dosage OK Question Title * 13. Camper is up to date on all Public School Immunization Requirements Yes No If no, please elaborate: OK Question Title * 14. Camper has received the flu vaccine in the past 6 months OR will be receiving it prior to Midwinter 2020. Yes No OK Question Title * 15. What is the camper’s swimming ability Beginner Intermediate Advanced Nonswimmer OK Question Title * 16. Camper’s Family Doctor Name Phone Number OK Question Title * 17. Please provide 3 emergency contacts and phone numbers: Name & Phone # Name & Phone # Name & Phone # OK Question Title * 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. Yes No OK Question Title * 19. Camper T-shirt Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XLarge Adult XXlarge Adult XXXlarge AdultXXXXlarge OK Question Title * 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. Yes No OK Question Title * 21. The Midwinter 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. OK Question Title * 22. Campers will be housed in hotel style rooms with Counselor oversight, do you have any special requests for housing? OK DONE