Augustine Rainbow Camp Camper Application and Health History 2024
Camper Name
*
First Name
Last Name
Camper Gender
Camper's Date of Birth
*
-
Month
-
Day
Year
Date
Age of camper at start of camp (June 24, 2024):
*
Has your camper attended Augustine Rainbow Camp in the past?
*
Yes
No
Primary Contact Email (This is our primary way to contact you about your application status and other important camp information, so please list an email that you check regularly)
*
example@example.com
Re-Type Primary Contact Email
*
example@example.com
Camper T-Shirt Size
*
Youth XS
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contacts
Primary Parent/Guardian to be notified in case of illness, injury, or other emergency:
*
Additional Emergency Contact #1
*
Additional Emergency Contact #2
*
Additional Emergency Contact #3
*
Doctor Information
*
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Health History
This camper's immunizations are UP TO DATE:
*
Yes
No
Date of Camper's Last Tetanus Shot
*
-
Month
-
Day
Year
Date
Does this camper have any allergies?
*
Yes
No
Please list all FOOD, ENVIRONMENTAL (insect stings, hay fever, etc.), MEDICINE and any other allergies, including the reaction seen, if applicable:
*
List ALL MEDICATIONS taken by camper and reason for medication:
*
The following non-prescription medications will be stocked in the camp office for use on an as needed basis. Check next to each medication to indicate permission to administer the medication to your child.
*
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Diphenhydramine (Benadryl)
Loratadine (Claritin)
Calcium Carbonate (Tums)
Generic Cough Drops
Calamine Lotion
Topical Antibiotic Cream/Ointment
None of the Above
List any activities the camper is unable to participate in for health reasons:
*
General Camper Information: Please check all that apply
Asthma
ADD/ADHD
Seizures
Heart Trouble
Bleeding Disorder
Skin Condition
Crohn's/Collitis
Kidney Disease
Diabetes
Deaf
Hearing Loss
Visually Impaired
Behavior Disorder
Developmental Disability
Diet Restrictions
None of the Above
Other
If applicable, please provide us with any additional information involving the previous question that will allow us to best serve the needs of your child:
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Demographics
We encourage you to answer the voluntary demographic questionnaire. This information is confidential and does not affect your application with Rainbow Camp. This data helps us understand our community and assists Augustine Rainbow Camp in developing programming and submitting for grants and donations. Thank you!
Gender
Male
Female
No Response
Number of People in Your Household:
Marital Status
Single
Married
Divorced
No Response
Ethnicity and Cultural Background (Please select all that apply)
White
Black or African American
American Indian or Alaskan Native
Asian, Native Hawaiian, or other Pacific Islander
Hispanic or Latino
Military Status:
Disability Status:
Average Annual Household Income
Below $10,000
$10,000-$50,000
$51,000-$100,000K
Over $100,000
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This health history is correct in so far as I know, and the person here in described has permission to engage in all camp activities except as noted.
*
In case of an emergency, I understand every effort will be made to contact me. In the event that I cannot be reached, I give permission to Augustine Rainbow Camp Staff to transport my child to source of medical care and for a copy of this form to be sent with my child. I also give permission to the physician selected by the camp staff to secure treatment, hospitalize, perform x-rays, routine test, anesthesia, surgery and administer emergency medications for my child named above.
*
I give permission to Augustine Rainbow Camp and St. Augustine Church to take and use photographs/videos of my child for promotional and informational purposes.
*
Deposit/Application Fee
*
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Deposit
Deposit will be directly applied to your camper's tuition fee. Deposit is non-refundable unless your camper is not accepted into the program.
$
60.00
Quantity
1
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Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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