Camp Wilmot 2023 Registration Form

Camp Wilmot 2023 Camper Registration Form
Camper Name:*

First NameLast Name
Camper Birth Date:*

MonthDayYear
Camper Email Address:
Camper Preferred Pronouns:
Camper Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Church Information

Please fill out this section if the camper attends a church at home. This may not be applicable for all campers.
Name of Home Church:
Denomination of Home Church:
Address of Home Church:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for Home Church:

Area CodePhone Number

Contact Information
What caregivers/guardians does the camper live with?*
Parent/Guardian 1's Name:*

First NameLast Name
Relationship to the Camper:*
Contact Phone Number 1:*

Area CodePhone Number
Type of Phone:*
Contact Phone Number 2:

Area CodePhone Number
Type of Phone
Email Address:*
Parent/Guardian 2's Name:

First NameLast Name
Relationship to the Camper:
Contact Phone Number 1:

Area CodePhone Number
Type of Phone:
Contact Phone Number 2:

Area CodePhone Number
Type of Phone:
Email Address:
example@example.com
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Relationship to the Camper:*
Emergency Contact Phone Number 1:*

Area CodePhone Number
Type of Phone:*
Emergency Contact Phone Number 2:

Area CodePhone Number
Type of Phone:
Email Address*
example@example.com

Diet, Activity, Allergies
Does the camper have any dietary restrictions?*

YesNo
Please explain the camper's dietary restrictions:
Does the camper have any activity restrictions?*

YesNo
Please explain the camper's activity restrictions:
Please list any allergies the camper has (food, medication, other):*
If the camper does not have allergies, please write none.

Insurance and Healthcare Providers
Is the camper insured by family medical/hospital insurance?*

YesNo
Please upload a picture of the front and back of the insurance card

Browse Files

Cancelof
Primary Care Provider
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Dentist
Name:

First NameLast Name
Phone Number:

Area CodePhone Number
Healthcare Provider Form
Please upload a healthcare/physical/medical information form from the camper's healthcare provider*

Browse Files

Cancelof
I certify that my healthcare provider form is within one year of the time the camper will attend camp.*

Yes

Camper/Family Agreements, Waivers, and Releases
Parent/Guardian Agreement: I give full permission for my camper to attend Youth Camp at Camp Wilmot and to participate in all phases of the program. I understand that every effort will be made to protect and safeguard all campers. Therefore, I agree not to hold the Presbytery of Northern New England, Camp Wilmot, its Board of Directors or its agents liable for any illness or for any mishap from any cause whatsoever which may be sustained. I understand that a Medical Information Form, signed by a physician, must be turned in prior to the start of camp, and the camper must have had a physical within one year of the start of camp. I authorize Camp Wilmot staff to handle all matters of discipline. I understand that any camper disregarding camp rules will be sent home with no refund of their camp fee. I understand that any camper who willfully destroys or defaces any property will be responsible and charged accordingly.*

Yes
Parent/Guardian Signature*

Powered by Jotform Sign Clear
Camper Agreement: I wish to participate in a Youth Camp program at Camp Wilmot and agree to abide by camp rules and will do my best to make the experience a success for all.*

Yes
Camper Signature*

Powered by Jotform Sign Clear
Youth Waiver and Release of Liability Agreement

In consideration for my camper being permitted to participate at Camp Wilmot, in related events and activities, the undersigned acknowledges and agrees that as the natural parent and/or as the legally authorized guardian, do hereby for myself, my spouse, my child, and on behalf of my/our heirs, personal representatives, and assigns, agree not to sue and hereby release, waive, discharge, hold harmless and indemnify and forever defend Camp Wilmot from any and all liability, losses, claims, actions, suits, procedures, demands, rights, and causes of action of whatever nature, in law and equity, for any and all known or unknown, foreseen or unforeseen, bodily or personal injuries, death and permanent injury, illnesses, damage to property, or other losses, and any consequences thereof, including expenses, costs, and attorney’s fees, as may be sustained by my camper or me arising out of or in any way associated with my camper’s participation at Camp Wilmot, or travel incident thereto, whether by negligence or not to the fullest extent permitted by law. The risk of serious injury to my camper from these camp activities does exist including the potential for permanent disability and death. I understand and fully acknowledge that my camper’s participation in these activities is solely at our own risk and I assume full responsibility. I hereby further declare that my camper has had a physical examination within the past year and is physically able to participate in all camp activities. Moreover, I hereby understand and affirm that the camp only provides for excess medical insurance and any charges including deductibles related to the medical care provided to my camper will be the responsibility of my primary insurance carrier or me.
I HAVE CAREFULLY REVIEWED AND VOLUNTARILY AGREE TO THE TERMS OF THIS CAMP WAIVER AND RELEASE OF LIABILITY AGREEMENT.*

Yes
Parent/Guardian Signature*

Powered by Jotform Sign Clear
Media Release: I authorize Camp Wilmot to take and use photographs, slides, and videotapes of myself or my camper without compensation for the purpose of promotion and/or website use.*

YesNo
Off-Site Waiver: I give my permission to Camp Wilmot to take my camper on short walks outside of camp property, not to exceed a distance of 2.5 miles from camp. I further absolve the camp of all responsibility for any accident or injury that may occur due to causes other than gross negligence on the part of Camp Wilmot or its staff. Should any difficulties arise, the situation will be dealt with according to the policies of Camp Wilmot.*

YesNo
Off-Site Transportation Waiver: I give my permission to Camp Wilmot and the Director Team to transport my camper in a Camp designated vehicle off-site. I understand that my camper is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my camper may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.*

Yes
Authorization: This health history is correct and accurately reflects the health status of the individual to whom it pertains. The person described has permission to participate in all camp activities except as noted above and/or by an examining licensed medical professional. I give permission to the licensed medical professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the individual for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the individual. I understand the information on this form will be shared on a 'need to know' basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of the described individual's health record from providers who treat them and these providers may talk with the program's staff about the described individual's health status.*

Yes
Parent/Guardian Signature for Media Release, Off-Site Wiaver, Off-Site Transportation Waiver, and Authorization*

Powered by Jotform Sign Clear

Payment

Please select your payment method and the weeks the camper is attending camp. Tuition must be paid upon arriving at camp. Checks can be sent to 6 Trestle Way Dover, NH 03820. FAMILY if there are multiple campers per family. CAMPERSHIP (please talk to directors first).
How would you like to pay camp tuition?*

PayPalSend a checkVenmoCampership (please talk to directors before submitting the form if selecting this option)

Youth Camp 1$600.00

Youth Camp 2$600.00

Adventure Camp$850.00

Enter coupon

Total $0.00

Please use this link to pay camp tuition via PayPal.

Please use this link to pay camp tuition via Venmo.
Should be Empty:

Camp Wilmot 2023 Camper Registration Form

Participation Information

Church Information

Contact Information

Emergency Contact Information

Diet, Activity, Allergies

Medications and Health History

Immunizations

Insurance and Healthcare Providers

Primary Care Provider

Dentist

Healthcare Provider Form

Camper/Family Agreements, Waivers, and Releases

Payment