PERSONAL CAMPER INFORMATION
*Gender
Gender
*T-Shirt Size
T-shirt sizes
*Grade
Grade entering in Fall 2018
*Age of Camper
Age as of first day of camp
*Birthday
Birthday - month, day, year
*Home Phone Number with Area Code
(xxx) xxx-xxxx
*Address
Street address/PO Box
*State
Church
The local church that the camper attends, if applicable.
Choice of Cabin Mate
Please choose only 1 cabin mate. Request must be mutual.
PARENT/GUARDIAN 1 INFORMATION
*Cell Number with Area Code
Work Number with Area Code
Home Number with Area Code
PARENT/GUARDIAN 2 INFORMATION
Cell Number with Area Code
Work Number with Area Code
Home Number with Area Code
EMERGENCY CONTACT INFORMATION
*Emergency Contact First Name
Please make this different from Parent/Guardian information. We will always contact Parents/Guardians first in case of emergency.
*Emergency Contact Last Name
*Emergency Contact Number with Area Code
*Allergies
Select all that apply:
Please specify below what the camper is allergic to and the reaction seen.
*Diet and Nutrition
Select one answer below.
Please specify below any diet/nutritional information that would affect a normal dining hall (buffet) meal time.
*Will the camper take any daily medications while attending camp?
List any medications with dosage/timing and reason for taking it.
Original packaging/containers are required with physician's instructions for dosage on the label.
The following non-prescription medications may be stocked at Camp and used on an as-needed basis to manage illness and injury. Please check which one(s) the camper should NOT be given.
*Choose any condition that applies to camper.
Please explain any conditions in the box below.
*Date of Last Tetanus Shot
MM/DD/YYYY
MENTAL, EMOTIONAL AND SOCIAL HEALTH
*Has the camper ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
*Has the camper ever been treated for emotional or behavioral difficulties or an eating disorder?
*During the past 12 months, has the camper seen a professional to address mental/emotional health concerns?
*Has the camper had a significant life event that continues to affect the camper's life?
History of abuse, death of a loved one, family change, adoption, foster care, disaster survivor, other
Please explain all "yes" answers in the box below.
*Do you Carry Family Medical Insurance?
Please submit a copy of the front and back of your insurance card by email (suzanne@sgaumc.com) or mail (Name of Camp, PO Box 20408, St. Simons Island, GA 31522). Insurance card must be received before or at time of registration.
Name of Insurance Company
Enter Policy/Group Number
*Permission to Seek Emergency Care
The information given on this registration form is correct and accurately reflects the health status of the camper to whom it pertains. The camper has permission to participate in all camp activities except as noted by me. I understand that in special situations, a medical doctor's statement may be needed. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. I understand the information on this form will be shared on a "need to know" basis with camp staff. Please type Parent/Guardian's electronic signature.
*Date of electronic signature above:
MM/DD/YYYY
Permission to Use Camp Photos in Future Promotions
Photos will be taken during camp that may be used for future camp promotions and our Facebook page. Please enter Parent/Guardian initials.
*I agree to this Honor Code.
As a good steward of what God has entrusted to me and to preserve my witness, I agree to protect, care for, and be responsible for the property of the place at which I stay/meet. I also agree to abide by any and all rules placed on me by these entities. Administration reserves the right to send any person or group home who jeopardizes the purpose of the event for others by their misconduct. As a representative of Christ and His Church, we take seriously our responsibility to one another and our concern for the well-being of the total community.
*Registration Fee
Please note that your child is not registered unless payment is completed online. For questions call Suzanne Akins, Camp Director at (912) 638-8626 ext.107.
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