Elementary 2 2018

*First Name
*Last Name
*Email
PERSONAL CAMPER INFORMATION
*Camper First Name
*Camper Last Name
*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
*City City
*State
*Zip Code Zip Code
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
*First Name
*Last Name
*Relationship to Camper
*Cell Number with Area Code
Work Number with Area Code
Home Number with Area Code
PARENT/GUARDIAN 2 INFORMATION
First Name
Last Name
Relationship to Camper
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
*Relationship to Camper
*Emergency Contact Number with Area Code
GENERAL HEALTH HISTORY
*Allergies

Select all that apply:

No known allergies
Food
Medicine
Environment (insect stings, hay fever, etc)
Other
Please specify below what the camper is allergic to and the reaction seen.
*Diet and Nutrition

Select one answer below. 

Regular Diet
Vegetarian
Lactose intolerant
Gluten intolerant
Other
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?
Yes
No
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.
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Antihistamine/Allergy Medicine
Diphenhydramine antihistamine/Allergy Medicine (Benadryl)
Sore throat spray
Generic cough drops
Lice Shampoo
Antibiotic Cream
Aloe
Nausea medicine (Pepto Bismol, Dramamine)
*Choose any condition that applies to camper.
Recurrent / Chronic Illness
Recent infectious disease
Recent injury
Asthma / Wheezing / Shortness of breath
Diabetes
Seizures
Headaches / Migraines
Fainting / Dizziness
Bedwetting
Skin Problems / Eczema
Gastrointestinal (Diarrhea / Constipation)
Other
No known health problems
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)?
Yes
No
*Has the camper ever been treated for emotional or behavioral difficulties or an eating disorder?
Yes
No
*During the past 12 months, has the camper seen a professional to address mental/emotional health concerns?
Yes
No
*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

Yes
No
Please explain all "yes" answers in the box below.
INSURANCE INFORMATION
*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.

Yes
No
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.

HONOR CODE
*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.

Yes
No
*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.

Credit Card Payment ($315)
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