Junior High Camp Registration 2022

Junior/Senior High Camp (June 19-July 23, 2023)
Camper Information
Camper Name*

First NameLast Name
Gender*
Birth Date*

MonthDayYear
The camper will be entering what grade the following school year.*
Has this camper attended Camp Caney before?*
Local Church Affiliation
T-Shirt Size*
Roommate Request
(Limit ONE please. We will try to honor these but there is no guarantee.)
FOR CAMPER: I agree to participate in all camp activities and to obey safety regulations and direction of the camp staff.*

Yes

For Parent/Guardian
I/We give full permission for our son/daughter to attend camp, participate in activities and group photo:*

Yes
Photographs may be used in camp publicity:*

YesNo
I/We give permission to share contact information with other campers*

YesNo
Please list 2 people who are designated to pick up your camper from camp on the final day of camp. For the safety of our campers, we will not allow a camper to leave camp with anyone else or at any time other than the last day of camp unless contacted and instructed otherwise by parent/guardian. Please contact Jessica at 318-245-3393 if you need to change arrangements for your children to be picked up at a different time or by another person that is not listed on this form.

Camper Health History Form

Please fill out your camper's medical information carefully and accurately.
In Case of Emergency
Parent/Legal Guardian to contact in case of emergency*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell/Alternate Phone*

Area CodePhone Number

General Medical History

Please fill out medical history as carefully and accurately as possible
Allergies

Please list any allergies your camper may have. If none, please type "none".
Food*
Medicine*
Environment*
Other*

Diet/Nutrition
This camper eats a regular diet*

YesNo
If you answered no, please explain.
Restrictions
Do you believe this camper can participate in all of the camping activities without restrictions?*

YesNo
If you answered no, please explain.

Medication

Please clearly label any medication and place in a ziploc bag with the camper's name on it.
Is there any medication this camper will need to take while at camp?*

YesNo
Name of medication and when it is given:
Does this camper have any allergies to any non-prescription medications?*

YesNo
If yes, please list the medication that the camper is allergic to.
Is it ok to give the camper over the counter medications for normal medical issues such as headache, upset stomach, nausea, and bug bites and/or stings?*

YesNo
Name of Family Doctor*

First NameLast Name
Phone Number*

Area CodePhone Number

Insurance Information

Please fill out each field accurately and clearly so that we have the correct information in the event of an emergency. In the event of a medical emergency, we will take appropriate measures to ensure your child is safe and will contact you at the emergency numbers listed above.
Do we have your permission to transport this camper to the nearest emergency room and/or hospital by way of personal vehicle and/or ambulance in the event of a medical emergency?*

YesNo
Is this camper covered by family medical/hospital insurance?*

YesNo
Name of Insurance Company:*
Policy Number:*
Subscriber*

First NameLast Name
Insurance Company Phone Number:*

Area CodePhone Number

Payment

$300
Payment Types*
prevnext( X )
Online$307.00

Check $ Free
Notice! Due to the costs of online registration a fee of $7.00 will be added to the total.

Once you "Submit Form" you will redirected to PayPal.com. On the "Add a Note" section in PayPal please note that this payment is for "Jr. High Camp for [Camper's Name]."
Pay by Check - $300.00

Please put your camper's name in the memo line and make your checks payable to Caney Conference Center and mail them to Camp Caney, 1163 Methodist Camp Road, Minden, La. 71055. Checks can also be brought to camp with you. (This information will be emailed to you once you click "Submit Form").
By submitting this form I agree that I have read and will abide by Camp Caney's Code of Conduct for Campers.
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Junior/Senior High Camp (June 19-July 23, 2023)