Boost Kids Camp 2012

Registration and Medical Release

* required information

Camper Info:

* Last:
Please enter a name. * First:
Please enter a name

* Birthdate:
Please enter a date. Not a valid date format. * Gender: M F

* Church:
Please enter your church or none if not applicable.

* Grade (2011-2012 school year): * T-Shirt Size:

* Street Address:
Please enter your address:

* City
Please enter a city. * Zip Code
Please enter your zip.Invalid format.

Parent/Guardian Info:

* Name:
A value is required.

* Home Phone:
Please enter your home phone or N/A * Cell Phone:
Please enter your cell number or N/A

* Email Please enter an email. Invalid email format.

Who will be picking your child up at the church at 1pm on Wed. Aug 15th?

* Name
Please enter a name. * Cell Phone
You MUST enter a cell number.

We will do our best to contact this person in the event that we will not arrive at our scheduled time.

Emergency Contact Information (other than Parent/Guardian)

* Name
Please enter a contact name. * Phone
Please enter a phone number.

Name Phone

Medical Information

Medications brought from home: All presecription and over-the-counter medications must be turned in at check in. All prescription medications must be in the original pharmacy bottle, labeled with the patient name and physicia's ordered dose on the back (e.g., pills in baggies are NOT okay). Non-prescription /over-the-counter medications, including vitamins and herbal supplements , must also be in their original containers. Campers are allowed to carry one inhaler with them at camp, if medically necessary.

PLEASE FILL OUT THE MEDICATION LIST WHICH CAN BE PRINTED FROM HERE

The following over-the-counter medications may be dispensed during or summer camp sessions as needed: acetaminophen, ibuprofen, antihistamine, throat lozenges, anti-nausea, anti-diarrhea, antibiotic ointment, anti-itch cream, ipecac, aloe, eyewash and sunscreen.

Please list any EXECPTIONS to the over the-counter medications listed above including allergies and reactions:

Please list any allergies or dietary restrictions and reactions:

Tetanus booster up-to date? Yes No

Immunizations up-to date? Yes No

List Current Medical Conditions:

Parent/Guardian Consent for Minors

"My child has my permission to participate in all activities on or off the grounds including transportation by bus or private vehicle during The Boost Kids Camp 2012. In case of a medical emeergency for my child, I hereby authorize camp and/or church staff to act in their best judgement to seek medical attention through appropriate means, including emergency room treatment as deemed appropriate by attending medical personnel. I also accept responsibility for expenses incurred through such treatment."

By entering your name below, you are stating that you've read the consent information and do consent. Entering your name will be a binding signature.

Enter your full legal name: You MUST enter a name.

Payment Information

Camper Cost - $215 *
5 Jr. Counselor/Extra Staff - $105

I would like a scholorship application

All registrations require a minimum deposit of $35.00

(This deposit is subracted from the camper fee and is refundable in the event that the camper does not attend camp)

* Scholarships are available for campers only. We want every child to have the opportunity to go to camp! If you need help with the $215 camper fee, please request a scholarship application.