Registration & Health History LGP International Camp

Registration and Medical History Form LGP International Camp

Please have pictures or pdf's of your Camper's insurance card(s) and immunization records BEFORE starting this form and on the same device you are completing this form on. You will need to upload these documents while registering. Payment will be collected at the completion of this form with a credit card or through PayPal. Thank you!
Registration Costs for 2022

$260 - Girls who are not currently registered with a caravan

$230 - Girls registered with National office through a caravan

$70 - Junior Leaders

Due to increased costs of camping, food, and other supplies registration costs have increased.

Deadline: June 30, 2022
Name of Camper *

First Name Last Name
Birthdate *

Month Day Year
Date
Caravan #, Name of Church, City/State (N/A if doesn't apply) *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Email *
example@example.com
Parent/Guardian Phone *
Please enter a valid phone number.
Parent/Guardian #2 Name

First Name Last Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Phone
Please enter a valid phone number.
Physician Name *
Pysician Phone Number *
Please enter a valid phone number.
Dentist Name *
Dentist Phone Number *
Please enter a valid phone number.
Health History and Examination Form

Please answer the following questions about each camper to provide camp health care personnel the camper's background so they may provide appropriate health care. Campers are not allowed to keep medication in their dorms. All medication will be handed out by the camp nurses. Please provide complete information so that camp can be aware of your child's needs. Thank you!
Does Camper have Medical Insurance? *

Yes No
Medical Insurance Carrier *
Policy Holder Name *
Policy Number *
Group Number *
Policy Holder's Date of Birth *

Month Day Year
Date
Please upload a picture of the FRONT and BACK of your medical insurance card. *

Cancel of
Is Camper current on all immunizations? *

Yes No
Please upload a copy of Camper's up-to-date immunization record. *

Cancel of
Recent injury, illness, or infectious disease? Provide dates and explaination. Type NONE if not applicable. *
Chronic or Recurring Illness/condition? Explain. Type NONE if not applicable. *
Emotional Difficulties? Explain. Type NONE if not applicable. *
Does Camper experience any of the following: Sleepwalking, Abnormal Menstrual Cycle, Bedwetting, Eating Disorder, or anything else not addressed? Explain. Type NONE if not applicable. *
FOOD Allergies - List all known allergies, reactions, and management. If no food allergies type NONE. *
MEDICATION Allergies - List all known allergies, reactions, and management. If no Medication allergies type NONE. *
OTHER Allergies - List all known other allergies, reactions, and management. If there are no other allergies type NONE. *
Signature - Registration and Health History Info is Correct. *

Clear

Permission to Treat

I hereby authorize and grant representatives with Lutheran Girl Pioneers and LGP International Camp to treat and give the medications authorized to my camper. I further give permission to LGP representative(s) to treat and/or seek treatment for any injuries that my camper may incur while I am not present.
Signature - Permission to Treat *

Clear

Shirt Size - Adult Sizes *
First time camper at LGP International Camp? *

Yes No
Previous Campers - Number of years attended?
Requested Cabin Mate(s) (up to 3)
Campers are grouped into cabins by grade level. You are encouraged to request a friend to room with at camp. We will do the best we can to assign you with at least ONE of your requests. Please understand we cannot guarantee these requests.
Release and Hold Harmless Agreement

As the parent or guardian of a camper in the Lutheran Girl Pioneers International Camp Program, I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume full risk of any injuries, damages or losses, which I may sustain as a result of allowing my child to participate in with any and all activities connected or associated with this program. I agree to waive and relinquish all claims against Marinette County and its officers, agents, and employees I may have as a result of allowing my child to participate in the program for any and all claims from injuries, damages, or losses, which I may have or may incur on account of my negligence during my child's participation. I agree to idemnify, hold harmless, and defend Marinette County and LGP International Camp, thier officers, agents, volunteers, and employees from all claims resulting from injuries, damages, and losses sustained during and arising out of the activities of the program. I have read, fully understand, and agree to the above Release and Hold Harmless Agreement.
Signature - Release and Hold Harmless Agreement *

Clear

Select appropriate camper option. *

Camper - Not active Girl Pioneer

$ 260.00

Camper - Active Girl Pioneer registered with National office through local Caravan. Check with Caravan leader if unsure.

$ 230.00

Junior Leader 11th or 12th Grade Only

$ 70.00

Donation to LGP Camp Would you like to add a donation to Lutheran Girl Pioneers Camp? Money collected will be used to help cover PayPal transaction fees, expenses, prizes, etc. for the LGP International Camp. All donations in any amount are greatly appreciated! Your generosity matters.

$ 1.00 Quantity
Item subtotal: $ 0.00

Enter coupon

Total

$ 0.00

Pay with PayPal

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Registration and Medical History Form LGP International Camp