NWCCD 2025 CAMPER REGISTRATION

NWCCD 2025 CAMPER REGISTRATION

Registration is required for each person attending camp
We are excited to have you at camp this year!! Camp will occur on Monday July 21st 2025 to Saturday July 26th 2025. Check in at camp starts at 2:20 pm on Sunday. Pick-up on Friday starts at 10:00 am. When filling out this form you are not required to submit payment right away. Because of the COVID situation and uncertainty of what things will be like in July we want to encourage people to submit the registration forms but hold for payment at a later date when we have a clearer picture. At that time we will notify you for payment and how to pay. Thanks!!

If you have anyquestions feel free to contact me.

Email: nwccd2011@yahoo.com

Phone (Text or voice) 360-771-9511

Jim Smith

Director NWCCD
Select Registration Type*

Babies and Pre-KindergartenCamper (Elementary, Middle School, High School)Adult Camper (e.g. Non-volunteer parent staying at camp)
APPLICANT PROFILE

This section must be completed
Applicant Name*

First NameLast Name
Applicant Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Gender*

MaleFemale
Applicant Date of Birth*

MonthDayYear
Applicants Age?
Applicant Grade in the Fall of 2025*
Applicant American Sign Language Fluency

BeginnerIntermediateAdvanced
Applicant Superpower

DeafHard of HearingHearing
Applicant Marital Status

SingleMarried
Applicant Cabin Request

Applicant will sleep in cabin with other campers (same school group)Applicant will sleep in cabin with family
Applicant Email
example@example.com
Applicant Cell Phone Number
Please enter a valid phone number.
Applicant VP Phone Number
Please enter a valid phone number.
Applicant Residential Phone Number
Please enter a valid phone number.
PARENT/GUARDIAN

This section is required if applicant is less than 18 years of age
Parent/Guardian Name

First NameLast Name
Parent/Guardian Superpower

DeafHard of HearingHearing
Parent/Guardian Email
example@example.com
Parent/Guardian Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Cell Phone Number
Please enter a valid phone number.
Parent/Guardian VP Phone Number
Please enter a valid phone number.
Parent/Guardian Residential Phone Number
Please enter a valid phone number.
STATEMENT OF CONSENT AND AGREEMENT BY APPLICANT

Applicant is required to acknowledge and sign
I, {ApplicantName}, acknowledge that I have read the rules and regulations of NWCCD. I will follow all water safety rules of the camp, follow designated schedules, attend all meals unless excused by the nurse, not use radios, TVs, stereos, iPods, Sidekicks, or CD players while at camp, follow the dress code, and comply with any other rules and regulations the camp may set.

I, {ApplicantName}, agree to follow all the rules and regulations of NWCCD, knowing that if I do not, I may be dismissed from camp without refund and will have to pay for any travel arrangements made necessary as a result. I will also be held financially responsible for any malicious damage I do to the camp or any other camper’s property.

I, {ApplicantName}, acknowledge that if I am unyielding to any rules, I will be sent home at my own expense and inconvenience or, if under 18, the parent’s expense and inconvenience.
Applicant's Age
Date of Consent and Agreement by Applicant*

MonthDayYear
Applicant's Signature*

Clear
STATEMENT OF CONSENT AND AGREEMENT BY PARENT/GUARDIAN

If Applicant is under 18, a Parent/Guardian is required to acknowledge and sign
If the Applicant is under 18, a parent/guardian must sign.

I, {ParentGuardianName}, acknowledge that I have read the rules and regulations of NWCCD. The Applicant is expected to will follow all water safety rules of the camp, follow designated schedules, attend all meals unless excused by the nurse, not use radios, TVs, stereos, iPods, Sidekicks, or CD players while at camp, follow the dress code, and comply with any other rules and regulations the camp may set.

I, {ParentGuardianName}, acknowledge that the Applicant may be dismissed from camp without refund and I will have to pay for any travel arrangements made necessary as a result. I will also be held financially responsible for any malicious damage the Applicant does to the camp or any other camper’s property.

I, {ParentGuardianName}, acknowledge that if the Applicant is unyielding to any rules, the Applicant will be sent home at my own expense and inconvenience.
Date of Consent and Agreement by Parent/Guardian*

MonthDayYear
Parent/Guardian's Signature*

Clear
STATEMENT OF CONSENT AND AGREEMENT FOR PHOTOGRAPHY BY APPLICANT

If Applicant is over 18, Applicant is required to acknowledge and sign
As the Applicant, I give permission to be photographed during camp. The photos are shown during meals, camp blog and on the photo CD.*

YesNo
Applicant's Age
Date of Consent and Agreement by Applicant*

MonthDayYear
Applicant's Signature*

Clear
STATEMENT OF CONSENT AND AGREEMENT FOR PHOTOGRAPHY

If Applicant under 18, Parent/Guardian is required to acknowledge and sign
As Parent/Guardian, I give permission for the Applicant to be photographed during camp. The photos are shown during meals, camp blog and on the photo CD*

YesNo
Date of Consent and Agreement by Parent/Guardian*

MonthDayYear
Parent/Guardian's Signature*

Clear
HEALTH / MEDICAL CHECKLIST
Health/Medical Checklist for Applicant, {ApplicantName}
Applicant is permitted to engage in recreational activities such as running, swimming, competitive games and hiking*

YesNo
Applicant is permitted to swim (there are lifeguards on duty at the beach)*

YesNo
If No, explain why
Applicant has the following health conditions

AsthmaDiabetesEpilepsyOther
Applicant has other health conditions not listed above
Applicant requires the following for mobility

WheelchairCrutchesOther
Applicant has the following non-food allergies

PenicillinPoison OakBee StringOther
Applicant has the following non-food allergies not list above
Applicant has food or drink allergies

YesNo
Applicant had surgical operations in the past 12 months

YesNo
If Yes, please describe the nature of surgical operations
Applicant is known to Sleepwalk

YesNo
IN CASE OF ILLNESS OR INJURY

This section must be completed
IN CASE OF ILLNESS OR INJURY for Applicant, {ApplicantName}, after every reasonable effort has been made to contact parent/guardian of child 18 years or younger, or in the event that an adult camper is unable to authorize treatment, I authorize the camp nurse to sign in my place for necessary treatment by a local physician and/or for hospital care.
Parent/Guardian, {ParentGuardianName}
Date

MonthDayYear
Parent/Guardian's Signature for Camp Nurse to sign in my place for necessary treatment

Clear
APPLICANT EMERGENCY CONTACTS

This section must be completed
Emergency Contacts for Applicant, {ApplicantName}
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Superpower*

DeafHard of HearingHearing
Emergency Contact #1 Cell Phone Number
Please enter a valid phone number.
Emergency Contact #1 VP Phone Number
Please enter a valid phone number.
Emergency Contact #1 Residential Phone Number
Please enter a valid phone number.
Emergency Contact #1 Relationship to Applicant*
(e.g. Aunt, Grandpa, Cousin, etc.)
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Superpower*

DeafHard of HearingHearing
Emergency Contact #2 Cell Phone Number
Please enter a valid phone number.
Emergency Contact #2 VP Phone Number
Please enter a valid phone number.
Emergency Contact #2 Residential Phone Number
Please enter a valid phone number.
Emergency Contact #2 Relationship to Applicant*
(e.g. Aunt, Grandpa, Cousin, etc.)
Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.
Dentist Name

First NameLast Name
Dentist Phone Number
Please enter a valid phone number.
MEDICAL INSURANCE

This section must be completed
Medical Insurance for Applicant, {ApplicantName}

Insurance must be valid in the State of Oregon. If not, you are personally responsible for any medical expenses necessary for camper.
Applicant has Medical Insurance that is valid in State of Oregon*

YesNo
Health Insurance Company*
Health Insurance Phone Number
Please enter a valid phone number.
Health Insurance Member ID
Health Insurance Group ID
MEDICATION

This section must be completed
Medication Checklist for Applicant, {ApplicantName}

Attention All Campers! Please read this notice.

You will meet with the camp nurses during registration on Sunday. They will be checking your forms for accuracy and collecting your medication.

All your prescription medication must be in PHARMACY LABELED CONTAINERS.

Tell the nurse of any meds that you must keep in your possession for emergencies (asthma, allergies, heart conditions).
Applicant will bring prescription medication to camp*

YesNo
Applicant will bring over the counter medication to camp*

YesNo
Applicant has the following in their possession for emergencies

Asthma MedicationDiabetes MedicationEpilepsy Medication
CAMP NURSE PHARMACY

This section must be completed
Camp Nurse Pharmacy permission for Applicant, {ApplicantName}

The most common complaints during camp are stomach aches and headaches. The camp nurse pharmacy will have medication available to dispense. See below.
Parent/Guardian gives permission to Camp Nurse to dispense the following to the Applicant during camp

Ibruprophen (Advil)Acetaminophen (Tylenol)Liquid and tablet antacids (ex. Maalox)BenedrylNone of the Above
Parent/Guardian, {ParentGuardianName}
Date

MonthDayYear
Parent/Guardian Signature for Camp Nurse Pharmacy

Clear
APPLICANT PRESCRIPTION MEDICATION

This section must be completed
Perscription medication for Applicant, {ApplicantName}

If Applicant is bringing prescription medication to camp. Prescription medication is kept by the Nurse.
Prescription #1 Medication Name
Prescription #1 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Prescription #1 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Prescription #1 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Prescription #2 Medication Name
Prescription #2 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Prescription #2 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Prescription #2 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Prescription #3 Medication Name
Prescription #3 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Prescription #3 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Prescription #3 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Prescription #4 Medication Name
Prescription #4 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Prescription #4 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Prescription #4 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Prescription #5 Medication Name
Prescription #5 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Prescription #5 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Prescription #5 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Prescription #6 Medication Name
Prescription #6 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Prescription #6 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Prescription #6 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
APPLICANT OVER THE COUNTER MEDICATION

This section must be completed
Over the counter medication for Applicant, {ApplicantName}

If Applicant is bringing over the counter medication to camp. Over the counter medication is kept by the Nurse.
Over the Counter #1 Medication Name
Over the Counter #1 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Over the Counter #1 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Over the Counter #1 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Over the Counter #2 Medication Name
Over the Counter #2 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Over the Counter #2 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Over the Counter #2 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Over the Counter #3 Medication Name
Over the Counter #3 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Over the Counter #3 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Over the Counter #3 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Over the Counter #4 Medication Name
Over the Counter #4 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Over the Counter #4 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Over the Counter #4 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Over the Counter #5 Medication Name
Over the Counter #5 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Over the Counter #5 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Over the Counter #5 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
Over the Counter #6 Medication Name
Over the Counter #6 Dosage Amount
(e.g. one tablet, two tablets, etc.)
Over the Counter #6 Time to be Taken
(e.g. before, after or during breakfast, lunch and/or dinner, before bedtime, etc.)
Over the Counter #6 How to take Medication
(e.g. my mouth, injection, inhalant, etc.)
MEDICAL RELEASE

This section must be completed
Medical Release for Applicant, {ApplicantName}

Medical Release—Authorization for care, and Liability Agreement

I, {ApplicantName}, have had a physical examination in the past year and am able to attend NWCCD. I accept full responsibility for transportation, and/or any related costs for medical services, should the need for any service occur during the week of NWCCD. I authorize the camp nurse, camp physician, or camp director to transfer the above person to an advanced level of care facility for treatment, including a hospital, a clinic, and/or emergency transport vehicle. I authorize release of: Medical health history information, Health are provider, and Insurance information. I have medical insurance that is valid in the State of Oregon. I authorize the camp nurse to dispense medications as indicated on the NWCCD Medications Form. I have listed every medication on the NWCCD Medications Form.
Applicant, {ApplicantName}
Applicant Signature

Clear
Medical Release—Authorization for care, and Liability Agreement

As {ParentGuardianName} for {ApplicantName}, I declare that {ApplicantName} has had a physical examination in the past year and am able to attend NWCCD. I accept full responsibility for transportation, and/or any related costs for medical services, should the need for any service occur during the week of NWCCD. I authorize the camp nurse, camp physician, or camp director to transfer the above person to an advanced level of care facility for treatment, including a hospital, a clinic, and/or emergency transport vehicle. I authorize release of: Medical health history information, Health are provider, and Insurance information. I have medical insurance that is valid in the State of Oregon. I authorize the camp nurse to dispense medications as indicated on the NWCCD Medications Form. I have listed every medication on the NWCCD Medications Form.
Parent/Guardian, {ParentGuardianName}
Date

MonthDayYear
Parent/Guardian Signature

Clear
PERSONAL CARE ASSISTANT

This section must be completed
Personal Care Assistant for Applicant, {ApplicantName}

NORTHWEST CHRISTIAN CAMP FOR THE DEAF is designed for Deaf and Hard-of-Hearing people. If an individual requires personal care assistance for “Activities of Daily Living” that individual must provide the personal care assistant at their own expense. Furthermore, it is required that said personal care assistant provide full assistance for the camp attendee during NWCCD camp week. The personal care assistant must complete all NWCCD registration forms and all camp fees must be paid.
Applicant requires a Personal Care Assistant and the Personal Care Assistant will register as Staff.

YesNo
If Yes, Personal Care Assistant Name

First NameLast Name
SPECIAL DIET

This section must be completed
Special Diet for Applicant, {ApplicantName}
Applicant has Special Diet Needs for camp*

YesNo
Note from NWCCD Staff: Special food items are ordered two weeks before camp. If you do not get your request in before that time, then you will be responsible for special dietary needs.

Twin Rocks kitchen staff is able to help you with your special diet needs in two ways: by providing enough variety in the menu from which you may choose, and by making substitutions for some (although not all) menu items in order to give you well-rounded meals. The menus for this week/weekend are posted on the wall to the right of the podium.

You are welcome to bring into the Dining Center any food items to supplement what we are offering you. There is a small refrigerator in the dining room under the beverage counter where you may store these items. We do ask those with no dairy or no wheat allergies to supply their own milk and bread. We offer only fresh fruit as an alternative to dessert for diabetics, so please bring your own sugar-free desserts if you want them. We hope you join us often for future camps. Upon request, we are happy to supply the week or weekend’s menu ahead of time in order to help you with your planning.

Below, please list your special diet needs. Please be as specific as you can, i.e., “no dairy, no wheat, vegetarian, vegan, no peppers or onion, diabetic, etc.” Please list only those diet needs that are related to food allergies, medical issues, or lifestyle choices, but not food preferences. Thank you.
If Yes, describe Applicant Special Diet Needs
TRANSPORTATION

This section must be completed
Transportation permission for Applicant, {ApplicantName}

If applicant is older than 18, this section is not required
Applicant will go home with Parent/Guardian*

YesNo
If No, who is the Designated Driver #1 to take the Applicant home?

First NameLast Name
Designated Driver #1 Phone Number
Please enter a valid phone number.
Designated Driver #2 to take the Applicant home?

First NameLast Name
Designated Driver #2 Phone Number
Please enter a valid phone number.
Designated Driver #3 to take the Applicant home?

First NameLast Name
Designated Driver #3 Phone Number
Please enter a valid phone number.
Designated Driver #4 to take the Applicant home?

First NameLast Name
Designated Driver #4 Phone Number
Please enter a valid phone number.
Parent/Guardian's Signature to give permission for Designated Drivers to pick up Applicant

Clear
REGISTRATION FEES
Early Bird Discount

Registration forms submitted before June 1, 2025 get the Early Bird Discount which is $280 per camper for ages 3-7 and $440 per camper for ages 8 and up.

After June 1, 2025, the registration fees will be $300 per camper for ages 3-7 and $470 per camper for ages 8 and up.

You will receive an invoice from NWCCD with payment options.

You only need to calculate the registration fees once for the entire family.
How many children ages 3-7 are attending camp?
How many children ages 8 and up are attending camp?
Total children attending camp
Total Registration Fees before June 1, 2025 (Early Bird Discount)
$100 Deposit before June 1st
Total Registration Fees after June 1, 2025 (No Early Bird Discount)
Should be Empty:

NWCCD 2025 CAMPER REGISTRATION

APPLICANT PROFILE

PARENT/GUARDIAN

STATEMENT OF CONSENT AND AGREEMENT BY APPLICANT

STATEMENT OF CONSENT AND AGREEMENT BY PARENT/GUARDIAN

STATEMENT OF CONSENT AND AGREEMENT FOR PHOTOGRAPHY BY APPLICANT

STATEMENT OF CONSENT AND AGREEMENT FOR PHOTOGRAPHY

HEALTH / MEDICAL CHECKLIST

IN CASE OF ILLNESS OR INJURY

APPLICANT EMERGENCY CONTACTS

MEDICAL INSURANCE

MEDICATION

CAMP NURSE PHARMACY

APPLICANT PRESCRIPTION MEDICATION

APPLICANT OVER THE COUNTER MEDICATION

MEDICAL RELEASE

PERSONAL CARE ASSISTANT

SPECIAL DIET

TRANSPORTATION

REGISTRATION FEES