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Midwinter Registration 2024
1.
Camper Contact Information
Last Name
First Name
Congregation
Home Address
City/Town
State/Province
ZIP/Postal Code
Age
Email Address
Phone Number
2.
The camper is:
Male at birth, Identifies Male
Female at birth, Identifies Female
Male at birth, Identifies Female
Female at birth, Identifies Male
Male at birth, identifies Other
Female at birth, Identifies Other
3.
Grade Camper is currently enrolled in:
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
Counselor
4.
Parent/Guardian Information
Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
5.
The camper has a history of infection of:
Nose
Throat
Ears
Sinus
Lungs
Other (please specify)
6.
The camper is currently in good health
Yes
No-But noncontagious
No-Currently Contagious
Please comment further if checkmarked “No”
7.
Does the camper have any conditions requiring restricted activity?
Yes
No
If “Yes” please explain further.
8.
Is appendix present?
Yes
No
9.
Camper is subject to:
Sleepwalking
Convulsions
Asthma
Fainting
Hernia
Skin rashes
Mood disorders
Hyperactivity
Attention Deficit
Further explanation:
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:
11.
Has the camper been exposed to a contagious disease recently?
Yes
No
If yes, please elaborate further.
12.
Camper is currently on the following medications:
Name, Dosage
Name, Dosage
Name, Dosage
Name, Dosage
Name, Dosage
13.
Camper is up to date on all Public School Immunization Requirements
Yes
No
If no, please elaborate:
14.
Camper is up to date on the COVID vaccine OR will be receiving it prior to Midwinter 2024.
Yes
No
15.
Camper has received the flu vaccine in the past 6 months OR will be receiving it prior to Midwinter 2024..
Yes
No
16.
What is the camper’s swimming ability
Beginner
Intermediate
Advanced
Nonswimmer
17.
Camper’s Family Doctor
Name
Phone Number
18.
Please provide 3 emergency contacts and phone numbers:
Name & Phone #
Name & Phone #
Name & Phone #
19.
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
20.
Camper T-shirt Size
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult XXlarge
Adult XXXlarge
AdultXXXXlarge
21.
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
22.
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 office.
I am unsure. Please contact me to discuss arrangements.
23.
Campers will be housed in hotel style rooms with Counselor oversight, do you have any special requests for housing?
Current Progress,
0 of 23 answered