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Day Camp Registration Form
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Indicates required field
Name
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First
Last
Primary Phone Number
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Email
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Gender
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Male
Female
Birthdate
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Two digit month, two digit day, four digit year.
Address
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Line 1
Line 2
City
State
Zip Code
Country
Cabin friend request
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T-Shirt Size
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Youth X-Small
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Parent or Guardian #1
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First
Last
Gender
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Male
Female
Phone Number
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Parent or Guardian #2
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First
Last
Gender
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Male
Female
Phone Number
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Emergency Contact (Other than Parent or Guardian)
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First
Last
Relationship to camper
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Phone Number
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Church most frequently attending
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Has the camper made a decision to follow Christ?
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Yes
No
Unknow
Has the camper been baptized?
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Yes
No
Unknown
Has your camper ever had:
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No health problems
Heart trouble
Diabetes
Seizures
Asthma
Rheumatic fever
ADD/ADHD
OCD
Other/Multiple: (list below):
Other
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Please describe your camper's medical history: List medical concerns, accommodations requested, and other details which may prevent camper from enjoying full and equal participation at camp:
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Generally this child's health is:
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Very good
Good
Sometimes Good
Sometimes poor
Has the camper discontinued any prescribed medications for the summer?
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Yes
No
Are all shots current?
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Yes
No
Does the camper need to carry an epi-pen?
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Yes
No
Please list any current medications (prescription or over-the-counter), dosages, and instructions including allergy medications:
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List the medications you will bring to camp. We require that medicine be in its original packaging with the camper's name on it.
Please list any allergies to medications:
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Please describe any food allergies:
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Other allergies:
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Medication Release
• All medications (including over-the-counter medicine and vitamins) must be turned in to the first-aid staff at registration in a ziplock bag at registration, and administered by the first-aid staff during camp.
• All medications must be in original packaging.
• Please include written instructions for EACH medicine in the bag with: Camper's name, list of medicine contained in the bag, explanation of what the medicine is used to treat, dosage amounts, and frequency of dosage for each medication.
• First-aid staff will not accept or distribute any medication not in the original container.
• Medication must be picked up by parent or guardian from the first-aid station at the end of camp.
Medical Treatment Release
I hereby give permission to the medical personnel selected by the camp director to provide routine health care; to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above.
Medication and Treatment Release:
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Yes I agree
No I don't agree
Medical Insurance Provider (if none write "none")
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Policy Number
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Photography Release
I understand that, while Camper is participating in Camp activities, photographs, film, audio recordings and videotape of Camper may be taken for use in brochures, videos, releases to the press, and various Sierra Christian Service Camp publications and other work product. I do hereby irrevocably grant Sierra Christian Service Camp permission to record, display and/or reproduce Camper’s name, likeness and voice on audio and/or video tape, film or other media, to edit and otherwise modify such media at its discretion, to incorporate the media into any work product, and to use or authorize the use of such media or any portion thereof in any manner or media or by any means, methods or technologies now known or hereafter to be known.
Photography Release
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Yes
No
Adherence to camp Rules
I ensure that Camper will adhere to all of the Camp's policies and rules. If Camper fails to abide by established rules and/or standards of conduct, Camp staff reserves the right to send Camper home. If it becomes necessary to send Camper home, I hereby agree to provide transportation or to make travel arrangements for Camper and to assume the cost of these expenses.
Required adherence to rules
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Yes
No
Consent to Attend Camp
Prior to Camper’s participation in Camp activities, I acknowledge that involvement of Camper in the Camp may involve risk of property damage and of personal injury, illness or even death of Camper, including but not limited to the risks arising from transportation-related activities, recreational activities, accidents in the outdoors and rustic facilities, adverse weather conditions, and injuries and illness as a result of food-borne illnesses and allergic reactions. In addition, I understand that there may be other risks inherent in Camp activities of which I may not be presently aware.
By signing this Consent and Release of Liability, I warrant that Camper is fully capable of safely participating in all Camp activities, and I expressly assume all risks of Camper’s participation, whether such risks are known or unknown to me at this time. I further release Sierra Christian Service Camp, and their directors, officers, employees, volunteers, and agents, and other campers at the Camp, from any and all claims against any of them as a result of property damage or personal injury, illness or death of Camper as a result of participation in Camp activities, whether on or off Camp grounds. I agree that this release includes the ordinary, special and inherent risks described above, and other risks that I may not foresee or be aware of at this time. This Release of Liability is given on behalf of myself, my minor child (if Camper), and the heirs, family, estate, administrators, executors, personal representatives and assignees.
I hereby give my permission for this camper to attend and participate in the Camp.
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Yes
No
Binding Arbitration
To the extent any provision of this document is found to be unenforceable, such provision shall be deemed severable and shall not affect the enforceability of any other portion of this document, and shall be reformed to be in compliance with the law and construed to most nearly reflect the intent of the parties.
I agree that any dispute concerning, relating, arising out of or referring to the subject matter of this Registration Form shall be resolved exclusively by binding arbitration in Tulare County, California, according to the then existing commercial rules of the American Arbitration Association and the substantive laws of California.
Binding Arbitration
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Yes
No
Type Parent/Guardian's First and Last name as Signature of Document. I certify that I have read this registration form and all the information contained is true and correct to the best of my knowledge:
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First
Last
Submit Registration
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