Day Camp Registration

2023 Adult Camp Registration

Please note that Adult Camp will serve campers ages 23+ during the summer of 2023. For campers of other ages, please check out the many other camp options!
Camper's Full Name*

First NameLast Name
Camper's Gender*
Camper's Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please select the week that you will attend*

Adult Camp (August 25-27; arrive as early as 3:00 pm on the 25th and depart by 11:00 am on the 27th) $75
If not staying for the entire camp, what day would you like to arrive?
I understand that my spot at camp is not guaranteed until I have submitted a deposit of $30 or more. My $30 deposit may also be used as collateral for my first box of chocolate if I plan to use the candy sale to cover the costs of camp. I can use the "pay" tab under the "camps" dropdown on the website to submit a payment in any amount.*

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I authorize Kimball Camp YMCA to: 1) Seek medical treatment in the event that it is deemed necessary and my emergency contacts cannot be reached. 2) Use photos of me for publicity purposes.*

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Health Information
Emergency Contact's Phone Number*
Emergency Contact's E-mail
Emergency Contact's Relationship to Camper*
Food Allergies

Yes
Bee Allergies

Yes
Other Allergies

Yes
Allergy Description
Physical Limitations
I am covered by insurance

Yes
Insurance Company
All immunizations are up to date

Yes
In the event of a complaint of minor aches and pains, (headache, muscle ache, fever, cough, etc.) I give consent to Kimball Camp to administer the following:
Advil

Yes
Tylenol

Yes

Camper Medicine 1
Medicine Name
Medicine Purpose
Medicine Dose
Breakfast

Yes
Lunch

Yes
Dinner

Yes
Night

Yes
As Needed

Yes
Other: Please describe

Camper Medicine 2
Medicine Name
Medicine Purpose
Medicine Dose
Breakfast

Yes
Lunch

Yes
Dinner

Yes
Night

Yes
As Needed

Yes
Other: Please describe

Camper Medicine 3
Medicine Name
Medicine Purpose
Medicine Dose
Breakfast

Yes
Lunch

Yes
Dinner

Yes
Night

Yes
As Needed

Yes
Other: Please describe

Camper Medicine 4
Medicine Name
Medicine Purpose
Medicine Dose
Breakfast

Yes
Lunch

Yes
Dinner

Yes
Night

Yes
As Needed

Yes
Other: Please describe

Camper Medicine 5
Medicine Name
Medicine Purpose
Medicine Dosage
Breakfast

Yes
Lunch

Yes
Dinner

Yes
Night

Yes
As Needed

Yes
Other: Please describe

Camper Medicine 6
Medicine Name
Medicine Purpose
Medicine Dosage
Breakfast

Yes
Lunch

Yes
Dinner

Yes
Night

Yes
As Needed

Yes
Other: Please describe
Kimball Camp YMCA programs involve a variety of activities that may include warm-ups, games, group initiative problems, high and low ropes course elements, and a full range of other physical activities. The level of participation in any activity is at all times completely voluntary and up to the individual's choice. Yet there is a risk that must be assumed by each participant that he or she may suffer an emotional or physical injury.
HOLD HARMLESS AND INDEMNIFICATION AGREEMENT

In consideration of the privilege of using Kimball Camp YMCA Nature Center, I agree to assume the risk for any injuries, including death, that may be sustained by the participant named on this form while participating in activities planned and/or facilitated by Kimball Camp YMCA Nature Center, regardless of whether injury or death occurs on or off the Kimball Camp YMCA Nature Center campus. I further assume all responsibility for injury or death that occurs during the named participant's intended stay at Kimball Camp YMCA Nature that may result from the named participant's decision, whether intentional or unintentional, to decline to participate in a planned activity and/or depart from designated Kimball Camp YMCA Nature Center activity areas, grounds, staff supervision, or intended program. Further, I agree to indemnify, hold harmless, assume liability for and defend Kimball Camp YMCA Nature Center, its trustees, officers, employees, staff, members and agents from all costs and expenses including, but not limited to, attorney's fees, reasonable investigative and discovery costs, court costs, and any other sums which Kimball Camp YMCA Nature Center, its trustees, officers, employees, staff, members and agents may pay or become obligated to pay for injury, including death, to persons or damage to property resulting from the use of Kimball Camp YMCA Nature Center, or from our actions or omissions and arising from any cause, including vehicles, except for matters caused by the exclusive negligence or willful misconduct of Kimball Camp YMCA Nature Center, its trustees, officers, members and agents while acting within the scope of duties of such relationship to Kimball Camp YMCA Nature Center. By signing below, I hereby certify that I have the legal authority to sign this agreement on behalf of the participant named above.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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