Day Camp Only 8am-7:15pm Local Camp Registration

Does camper have any allergies?    Please Select Yes No *   
Is the camper subject to bed wetting? (overnight campers only)  Please Select Yes No *   
Is the camper subject to sleep walking?(overnight campers only)    Please Select Yes No *   
Are there any foods the camper should not eat?    Please Select Yes No Type Option 3 *   
Does the camper have asthma?    Please Select Yes No *   
Does the camper require an Epi-Pen?    Please Select Yes No *   

Date of last Tetanus shot?   Date   
Family Doctor:   First Name   Last Name   
Is the child cover under Insurance?    Please Select Yes No       
Medical Condition of Child:      
Medicare/Insurance policy #        
Group/Member #      
Insurance contact# (attach copy of card)    

Please list any medications, if any, your child will have at camp. (all medications are kept in the nurse's office and distributed per doctor's orders)
Medication:      Dosage/Frequency:      
Medication:      Dosage/Frequency:      
Medication:      Dosage/Frequency:      
Medication:      Dosage/Frequency:      

During a typical week at camp, it may be necessary to issue first aid and OTC medications. Examples are:
-Hydrogen Peroxide -Calamine Lotion -Cough Drops
-Mylanta -Pepto-Bismol -Rubbing Alcohol
-Eye Drops -Tylenol/Ibuprofen -Excedrin
-Vaseline - Aloe Vera -Ammonia Inhalant
-Triple Antibiotic Ointment
Other:      
(If a child takes meds, please fill out the medications form for the nurse)

I give permission to the nurse/med tech at Camp Penuel to administer the medications listed above to my child.

Signature*   Date*   

Parent/Guardian Release: 

By signing this form, I am giving permission for the listed camper to attend Camp Penuel. I verify the above information is correct. I waive and release Camp Penuel and its agents from any and all claims, demands, injuries, suits or causes of action, past, present, or future, arising out of our caused by myself or my child while participaitong in this camp, or should there be an injury traveling to or from camp. I grant permission for Camp Penuel and its agents to administer or arrange for emergency medical treatment in the event of accident, injury, or illness. Unless specified below with my signature, I give permission for myself or my child to be pictured or videotaped and my likeness to possibly be used in any of Camp Penuel's promotional materials.
Signature*   Date*   

To Be Read and Signed By Camper:

I agree to follow Camp Penuel's rules and guidelines. I also will obey staff members and counselors while at camp, and do my best to get along with other campers.

Signature*   Date*