Day Camp Registration Form Summer 2024

Day Camp Registration

Inclusive day camp for 3rd-5th grade 9am-5pm
Choose your camp date
Camper Name
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Camper's Information
Address*
City*
State*
Zip*
Home Phone*

Area CodePhone Number
Birth Date*

MonthDayYear
Year of Graduation*
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Email Confirmation
Parents Email
Other Information
How did you hear about Camp Collinswood?
Health Information
Choose camp dates
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration please see the nurse at that time. Please bring all medication in ORGIANAL CONTAINER. All prescriptions must be in that campers name and the correct dosage.
Are immunications up to date?*

YesNo
Date of last tetanus shot*
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.*
Payment Information

$175 Early Bird Registration Fee Due by Feb 29th. Price increases to $200 March 1st
Payment for camp is made online on the Aldersgate Camp Collinswood website. Click here to pay.

You'll be redirected to a site that says donate to Aldersgate homes.

Fill in payment amount

Choose to pay using paypal or debit/credit card.

If the name on your account is different from the name of the camper you are paying for. Please call so we can be sure to mark your camper as paid.

If you have any questions feel free to contact Michele at 425-647-7677.
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)*
- Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites. I authorize Camp Collinswood to use my camper's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the camp.
Signature*

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Day Camp Registration

Camper Name

Camper's Information

Parent or Legal Guardian Information

Email Confirmation

Other Information

Health Information

Payment Information

Camper Release