Kids Camp Registration Form
Camper First Name
*
Camper Last Name
*
Camper Gender
*
Boy
Girl
Camper Address Line 1
*
Address Line 2
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
ZIP Code
*
Camper's Birth Date (MM/DD/YYYY)
*
Camper's School Grade in Spring 2026
*
Please Select
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Camper's Age in July 2026
*
Camper's Home Church
*
Custodial Parent First Name
*
Custodial Parent Last Name
*
Custodial Parent/Guardian Phone #
*
Custodial Parent/Guardian Email
*
Cabin Mate Preferences
Campers may request to be placed in a cabin with another camper. Campers completing first - third grades are grouped together and campers completing fourth - sixth grades are grouped together.
Cabin Mate Choice #1 (Must be same age/grade/gender):
Cabin Mate Choice #2 (Must be same age/grade/gender):
Cabin Mate Choice #3 (Must be same age/grade/gender):
Counselor Request:
Back
Next
Emergency Contact Information
Please list two people who can be contacted in case the parent listed cannot be contacted.
Contact #1 First Name
*
Contact #1 Last Name
*
Emergency Contact #1 Phone
*
Contact #2 First Name
*
Contact #2 Last Name
*
Emergency Contact #2 Phone
*
Back
Next
Camper Medical Information
List all medications the camper is taking (drug name, reason):
*
Please list any chronic or recurring illnesses:
*
Please list any emotional or behavioral problems:
*
Will the camper be bringing an inhaler to camp?
Yes
No
Will the camper be bringing an epipen to camp?
Yes
No
Please list any camper allergies:
*
While at camp your camper may experience ailments which can be treated with over the counter medications. It is the practice of CCD Kids Camp to provide some medication for use on an as needed basis. The Camp Nurse, based on the assessment of the camper, will dispense these medications. It is preferred that these medications be dosed by your camper’s weight. If the weight is not known, the dosage will be determined by the camper’s age.
Ibuprofen
Tylenol (acetaminophen)
Anti-itch cream
Antibiotic ointment
None
Camper Weight
*
(Used to dose medication)
Camper Height
*
(Used to dose medication)
Are there any methods you use to help calm or refocus your child?
Is there any additional information you would like us to know about your child?
This health history is correct so far as I know, and the person herein described has my permission to engage in all prescribed camp activities, except as noted above. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the Camp Director to secure proper treatment, to hospitalize, to administer medications, anesthesia, and/or surgery as necessary for the child named.
Back
Next
Camper Guidelines
Please read the guidelines and sign below to indicate you have read and understand them.
Parent/Guardian Signature
Parent/Guardian Signature
Parent/Guardian Signature
SUBMIT FORM
Should be Empty: