TRAC Jefferson Camper Registration

TEEN REACH ADVENTURE CAMP
Jefferson T.R.A.C.

for children in foster care or relative placements Sponsored by Jefferson Baptist Church
Boys’ Camp: Aug 21-23, 2026

Girls’ Camp: Aug 28-30, 2026
CHILD REGISTRATION FORM
MaleFemale
Child's First Name*
Child's Last Name*
Child's Preferred Name (if applicable)
Custom Name
Birth Date*

MonthDayYear
Date
Age*
Current Emotional Age
Upload a current picture of the teen.

Cancelof
School*
Grade*
Reading Level
Foster ParentRelativeAdoptive ParentOther
Name(s) of Parent/Guardian Child is Living With*
First Name(s) of Others in the Household (and age if siblings)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
EmailTextPhoneMail
Cell Phone
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
YesNo, but has been in the pastNo
Child's Social Worker (if applicable)
Daytime or Cell Phone Number
Format: (000) 000-0000.
Moved in Foster Placement how many times?
Emergency Contact

if we can't get a hold of you while your child is at camp, who else can we contact?
Emergency Contact Name*
Relationship to Child*
Phone*
Format: (000) 000-0000.
Explain any unusual family circumstances that make camp especially important for the child.
(for example: recent crisis, being moved in foster placement, severe economic needs, etc.)
Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult Large
CAMPER DETAILS

Information provided on this form will help us prepare our staff to work with your child.
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
OftenSometimesNot At All
If selected "Often" or "Sometimes" above, please explain below. In addition, provide any information about possible triggers as well as what helps/strategies for redirection
GoodPoorDon't Know
NoYes
Please Explain*
NoYes
NoYes
Where (city or sponsoring church)?*
Any specific activities to be encouraged?
Any specific activities to be restricted?
NoYes
HEALTH HISTORY

Indicate all known allergies, illness, disabilities, physical limitations, or medical complications.
NoYes
Allergies to what? Describe symptoms/reactions and treatment.*
NoYes
Allergies to what? Describe symptoms/reactions and treatment*
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
If you selected "Yes" to any of the above items, please provide details, date of illness, severity, complications, and any residual impairments.
Any other illnesses or medical complications?
Any other disabilities/limitations?
IMMUNIZATION HISTORY
Please fill in dates of basic immunizations and most recent booster as best as you can OR attach a print out of the child's immunization history.
DTP Series

MonthDayYear
Date
DTP Booster

MonthDayYear
Date
German Measles (Rubella)

MonthDayYear
Date
Chicken Pox

MonthDayYear
Date
Tetanus Booster

MonthDayYear
Date
Measles Vaccine (live)

MonthDayYear
Date
Mumps Vaccine (live)

MonthDayYear
Date
Typhoid

MonthDayYear
Date
Polio OPV (Sabin)

MonthDayYear
Date
Tuberculin (TB) Test

MonthDayYear
Date
Small Pox

MonthDayYear
Date
PRESCRIPTION MEDICATIONS
NoYes
If yes, for what?*
Please fill in the following for all medication:
1. Medication Name
2. Reason Prescribed
3. Dosage
4. Times
All medication sent to camp must be in original container with the pharmacy label on it.
Medications
Medication Administration Permission

I understand that it is my responsibility as caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp. I hereby authorize RFKC's nurse to administer the above medication from during the dates of this camp.
Parent or Legal Guardian Name
Parent or Legal Guardian Signature

Clear
OVER-THE-COUNTER MEDICATIONS
I hereby give the Teen Reach Adventure Camp Registered Nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified. I trust the TRAC Registered Nurse to use his/her best judgment as situations arise, and if in doubt, he/she can call for verification.

Please check YES or NO for the medications listed below. This form must be completely filled out by the primary caregiver who signs below or camper may not attend camp.

Over-The-Counter Medications*

Rows	Yes	No
Sunscreen/Sunblock
Insect repellent
Lip Balm
Rash/antibiotic ointment
Tylenol/Advil
Antiseptic Ointment
Band-aids
Anti-itch cream
Hydrogen peroxide
Cough syrup
Cough drops
Decongestant
Antihistamine
Saline eye drops

Any other OTC Medication Restrictions?
Parent or Legal Guardian Name*
Parent or Legal Guardian Signature*

Clear
ADDITIONAL MEDICAL
Name of Child's Doctor *
Doctor's Phone*
Format: (000) 000-0000.
Child's Heath Insurance Provider
Child's Insurance Number(s)*
Upload a copy or photo of child's medical/insurance card

provide if you have one
Cancelof
Yes
Any other comments related to the child's HEALTH or MEDICATIONS?
MEDICAL RELEASE
This health history is correct so far as I know, and the above named minor has permission to engage in all prescribed program activities, except as noted. The undersigned do hereby authorize the directors of Teen Reach Adventure Camp or such substitute as they may designate as agent for the undersigned to consent to an X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor is in route to and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Teen Reach as legal guardian/social worker/other. I give my permission for the child listed below to attend Teen Reach Adventure Camp sponsored by Jefferson Baptist Church for the listed camp dates.
YesNo
Child's Name*
Parent or Legal Guardian Name*
Parent or Legal Guardian Signature*

Clear
Relationship to Child*
PERSON AUTHORIZED TO PICK UP CHILD

Please provide the name(s) of those authorized to pick the child up from camp. Individuals will have to provide photo ID when picking the child up after camp.
Name(s)*
Relationship to Child*
Additional Comments (optional)
Submitting this application does not guarantee your child a place in camp. You will be notified in the beginning of July as to your child's acceptance to camp.
Should be Empty:

TEEN REACH ADVENTURE CAMP

Jefferson T.R.A.C.

CHILD REGISTRATION FORM

Emergency Contact

CAMPER DETAILS

HEALTH HISTORY

IMMUNIZATION HISTORY

PRESCRIPTION MEDICATIONS

OVER-THE-COUNTER MEDICATIONS

ADDITIONAL MEDICAL

MEDICAL RELEASE

PERSON AUTHORIZED TO PICK UP CHILD