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Father/Legal
Guardian’s Name:
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Fax Number:
Employer/School
Name:
Employer/School
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Fax Number:
Church
Affiliation (if you have one):
Mother/Legal
Guardian’s Name:
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Fax Number:
Employer/School
Name:
Employer/School
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Fax Number:
Church
Affiliation (if you have one):
Child's Name:
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Male
or Female?
Age:
Birth Date:
Church
Affiliation (if you have one):
Child's Name:
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Male
or Female?
Age:
Birth Date:
Church
Affiliation (if you have one):
Child's Name:
Address:
City:
State
:
ZIP Code:
Telephone
Number:
Second Phone:
Email
Address:
Male
or Female?
Age:
Birth Date:
Church
Affiliation (if you have one):
For
Additional children, please include an additional
sheet of paper with complete information.
Health History Information
The
following information is to be completed by one of
the following authorized persons: parent,
guardian, or adult camper over the age of 18.
Complete for each family member and provide a copy
of immunization records for each family member.
Please
provide the following information for each member
of the family.
Flagged
for special needs:
Please
include detailed notes with health form.
Is
the camper having any of the problems listed
below?
01.
Hay fever, asthma, or wheezing:
02.
Eczema or frequent skin rashes:
03.
Convulsions/seizures:
04.
Heart trouble:
05.
Diabetes:
06.
Frequent colds, sore throats, ear aches (4
or more per year):
07.
Trouble with passing urine or bowel
movements:
08.
Shortness of breath:
09.
Speech problems:
10.
Menstrual problems:
11.
Dental problems:
12.
Other (please specify below):
Please
explain below any problem areas identified above
including any current infectious diseases.
If necessary, include an extra sheet of paper.
If
female, has she been told about menstruation
(answer if appropriate)?
Has
she menstruated (answer if appropriate)?
Please
explain below any operations or injuries. If
necessary, include an extra sheet of paper.
Explain
below any special health, behavioral, or emotional
considerations. If necessary, include an
extra sheet of paper.
Please
list medications needed or used (including
psychiatric). If necessary, include an extra
sheet of paper.
Kind:
Frequency:
Dosage:
Currently taking medication (yes or no)?
Kind:
Frequency:
Dosage:
Currently taking medication (yes or no)?
Kind:
Frequency:
Dosage:
Currently taking medication (yes or no)?
Kind:
Frequency:
Dosage:
Currently taking medication (yes or no)?
Health
History Information, Continued.
List
below special conditions to be watched for such as
ALLERGY (reactions to food, penicillin, or other
drugs), bedwetting, fainting, sleep walking, etc.
If necessary, include an extra sheet of paper.
Please
include a copy of the camper’s immunization
records for:
Polio
Date initial immunization
completed:
Date of most resent booster:
Mumps
Date initial immunization
completed:
Date of most resent booster:
Diptheria
Date initial immunization
completed:
Date of most resent booster:
Tetanus
Date initial immunization
completed:
Date of most resent booster:
Perlussis
(whooping cough)
Date initial immunization
completed:
Date of most resent booster:
Measles
Date initial immunization
completed:
Date of most resent booster:
Rubella
Date initial immunization
completed:
Date of most resent booster:
Hepatitis
B
Date initial immunization
completed:
Date of most resent booster:
Other
Date initial immunization
completed:
Date of most resent booster:
Should
the camper be restricted because of any physical
limitation or illness?
If
yes, please explain:
Name
of camper’s physician or health clinic:
Physician
or health clinic’s phone number:
Hospital
preferred for emergency treatment:
Health
insurance policy number:
I
certify that this information is true to the best
of knowledge.
I
give Presbytery Point Camp, licensed by the
Department of Human Services, permission to secure
emergency medical and/or emergency surgical
treatment for the above named minor child while
under its care.
In case of emergency, campers will be taken
to
Bell
Memorial
Hospital
in
Ishpeming,
Michigan.
Authorized
Person’s Printed Name:
Authorized
Person’s Signature:
Date:
Emergency
Contact Information
Emergency Contact
Person:
Emergency Contact Address:
Emergency Telephone Number:
Second Emergency
Contact Person:
Second Emergency Contact Address:
Second Emergency Telephone Number:
This camper may be
released at the close of the camping session to
only the following person(s):
Name:
Relationship to camper:
Name:
Relationship to camper:
Name:
Relationship to camper:
Permission
to Transport Campers
I,
, give Presbytery Point Camp permission to
transport my child/youth,
, to and from camp, if necessary, for the purposes
of program activities or in the case of emergency.
I understand that the vehicles the camp
drives are in good repair and that drivers have
been approved by the camp manager and are at least
21 years of age and older and in possession of a
current driver’s license.
Signature:
Date:
In
signing this registration form the camper and
his/her parent or guardian agrees to accept and
abide by the guidelines(RULES), procedures,
standards, and policies as they are set forth by
the camp and by the state's regulating agencies,
and also agrees to respect others involved in the
camp experience including the camp's neighbors and
visitors and
the camp's property and facilities. Campers
and staff are expected to share daily
responsibilities for maintaining basic camp
sanitation standards. We also release any
photographs in which we might be a subject for use
by the camp in its promotional efforts. The camp
agrees not to put close-up shots of camper faces
on publicly accessible webpages.
Camper's
Signature:
Printed
Name of Parent or Guardian:
Signature
of Parent or Guardian:
Camp
Fee
Enclosed (the
entire fee is due upon registration):
Make
checks payable to Presbytery Point Camp. Mail
them with complete registration information to:
Presbytery
Point, PO Box 795, Marquette, MI 49855
Camper
Fees (per camper):
Family
Camp: $200.00 age 12 and higher ... $120.00 ages 5
through 11 ... Free under age 5.
K-2
camp: $180.00
Save
$10 per camper when you register before May 1,
2008.
The number of camper slots are limited.
Campers
are accepted on a first-come-first-served basis. A
fee of $25 will be charged for processing
cancellations after June 1, 2008. The
camp may not refund fees if campers cancel
less than one week before the camping session
starts. The
camp will refund no fees to campers who
leave camp early or arrive late, are sent home
early, or are "no shows." A
limited number of camperships are available. Check
with the pastor of your local church for
information about financial assistance. |
