2026 Winter Camp Registration
February 7-8 | 6-8 Grade | Join us for Kimball Camp in Reading, MI
PARTICIPANT INFORMATION:
Participant Name
*
First Name
Last Name
Participant Phone Number
*
Format: (000) 000-0000.
Participant Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
Please select a month
January
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Day
Please select a year
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Year
Gender (for housing considerations only)
*
Male
Female
Participant School
*
Grade
*
6
7
8
List anyone specific you would like to room with
We cannot guarantee you'll be with requests, but we will do our best.
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PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name
*
First Name
Last Name
Address (if different than student address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
SECONDARY EMERGENCY CONTACT:
Secondary Emergency Contact
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
AUTHORIZED PICKUP PERSON(S):
If different than the names listed above.
Authorized Pickup Person(s)
First Name
Last Name
Authorized Pickup Person(s) Phone Number
Format: (000) 000-0000.
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MEDICAL INFORMATION
**If you do not have a physician or medical insurance, please put N/A in the spaces provided.**
Physician Name
*
First Name
Last Name
Physician Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the participant had a physical within the last 24 months?
*
Yes
No
Medical Insurance Company
*
Policy Number
*
Allergies - check those that apply and specify nature of allergic reaction:
*
None
Animals
Environmental
Medication
Food
Insects
Latex
Other
Non-Prescription Medications:
The following non-prescription medications may be used on an AS NEEDED BASIS to manage illness and injury. Please indicate below which medications the participant may NOT receive. These non-prescription medications will be administered by YFC staff according to manufacturer's labeled dosages unless a written statement (prescription) from participant's health-care provider authorizes a different dosage.
Check the medications a camper should NOT have:
*
All of these options are ok for the participant to have as needed
Acetaminophen (i.e. Tylenol)
Aloe Vera Gel
Antacid (i.e. Tums)
Antiseptic Wipes (Benzalkonium Chloride)
Bacitracin/Triple Antibiotic Ointment
Calamine Lotion
Diphenhydramine oral tablet (i.e. Benadryl)
Cough Drops
Hydrocortisone 1%/Anti-Itch Cream (i.e. Benadryl cream)
Ibuprofen (i.e. Advil)
Loperamide HCI (i.e. Imodium AD)
Loratidine (i.e. Claritin)
Menstrual Relief (i.e. Midol)
Sunscreen Lotion
Vosol Ear Drop (i.e. Swim Ear)
Medication Administration Instructions:
"If medicine is present during YFC activities, that medicine must have written instructions present with it during the activity from a doctor, parent, or legal guardian." Any medication, prescription or over-the-counter, brought to an YFC activity must have written medical instructions and dosage information from a physician, parent or legal guardian. All medications must be in the original container where issued.
List the name of medications, time of day for administering, things to consider for administering:
Please use this space to describe all details of dosing and administering of the prescription, non-prescription medications, and nutritional supplements participant is bringing with them, as well as any drug interactions that you are aware of with these medications prescriptions.
Medical Concerns
Please provide any additional information about your participant's health that you think important or that may affect their ability to participate in YFC activities.
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LIABILITY RELEASES
These releases MUST be completed by the parent/guardian of the participant, unless the participant is 18 years of age or older.
YFC Consent and Release of Liability: I represent that I am the participant named (if 18 or over) or the legal parent/guardian of the child named, who is under 18 years of age. In consideration for allowing my child to participate in this activity and ongoing YFC activities, I hereby consent to the foregoing on behalf of my child and agree that this release shall be binding upon me, my child, our heirs, legal representatives and assigns.*
I, the undersigned, agree to the terms above.
*
Date
*
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Month
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Middle School Winter Full Payment
$
80.00
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Payment Details
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