CAMP REGISTRATION

ALL CAMPERS MUST HAVE A PHYSICAL FROM A PHYSICIAN

CAMPER INFORMATION

First Name

Last Name

Gender

Male

Female

Birthdate

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

School

Grade Completed

Dietary Restrictions

Allergies

PARENT/GUARDIAN CONTACT INFORMATION

Parent/Guardian 1

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Work Phone Number

Cell Phone Number

Email

Parent/Guardian 2

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Work Phone Number

Cell Phone Number

Email

EMERGENCY CONTACT INFORMATION

Emergency Contact 1

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Work Phone Number

Cell Phone Number

Email

Relationship to Child

Emergency Contact 2

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Work Phone Number

Cell Phone Number

Email

Relationship to Child

MEDICAL RELEASE INFORMATION

Insurance Policy Number

Name of Health Insurance Provider

Primary Physician

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Hospital Preference

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Medical Problem

Required Treatment

Should a paramedic be called?

Medical Problem

Required Treatment

Should a paramedic be called?

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

If yes, explain.

CAMP FEES

One hundred twenty-five dollars ($120) is due no later than July 23rd. Camp scholarships are available on a first come first serve basis. If your child receives a camp scholarship, there is a portion of the fee that you will have to pay. Palestine members are given first priority.

Are you in need of a camp scholarship:

The financially responsible party signing this form understands and agrees to follow the Camp Fees Policy.

Terms of Agreement

Photo Release
I hereby give permission for my child to be photographed during the week of Camp Palestine. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Feather River College Mountain Kids Camp and its affiliates.

Initials

Camp Palestine staff, counselors or volunteers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Signature

Typed Name of Parent/Guardian:

Date