Camper Registration Form

Camper's Name

First NameLast Name

Birth Date

MonthDayYear

Age

Gender

MaleFemale

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Cell Number

Home or Work Number

E-mail

example@example.com

T Shirt Size: (adult)

Emergency Information #1

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Emergency Information #2

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

MEDICAL/INSURANCE INFORMATION

Health Insurance Company

Policy#

Expiration Date:

Primary Doctor's Name:

Doctor's Phone Number

Does the camper have any chronic illnesses, or medical conditions? If yes, please describe.

THE MEDICAL INFORMATION PROVIDED ON THIS APPLICATION WILL ONLY BE AVAILABLE TO CAMP STAFF, IF NEEDED, AND TO MEDICAL PERSONNEL IN CASE OF EMERGENCY

Does the camper have any allergies/food allergens? If yes, please describe.

How did the camper receive their injuries?

THE MEDICAL INFORMATION PROVIDED ON THIS APPLICATION WILL ONLY BE AVAILABLE TO CAMP STAFF, IF NEEDED, AND TO MEDICAL PERSONNEL IN CASE OF EMERGENCY

Is the camper required to wear pressure garments or splints? If YES, Please provide detailed instructions for care:

Does the camper have any artificial limbs? If YES, please provide detailed instructions for care:

List all medications, dosages, and times to be given:

IF YOUR CHILD REQUIRES MEDICATION, PLEASE SEND ONLY ENOUGH FOR HIS/HER STAY AT CAMP WITH DETAILED INSTRUCTIONS AND IN THE ORIGINAL CONTAINER

Have you been to Camp Amigo before? If yes, who was your counselor?

When going to camp, what are some of the things that you would like to do?

Are there any special food requests that we need to be aware of? (Vegan/Vegetarian, etc.?)

Release to use photos and/or film:

I authorize Children's Burn Camp of North Florida, Inc. (Camp Amigo) to capture photographs and video footage (digital or otherwise) of my child. I understand that these images and videos may be used to educate the public about burn injuries, promote prevention efforts, and raise awareness about camps like ours. Local media may visit on the final full day of camp, and my child may appear on television, in the news, or in print while enjoying camp activities. All photos and videos taken at camp will be used exclusively by Children's Burn Camp of North Florida (Camp Amigo) for these purposes. Camp staff and fellow campers will capture moments throughout various activities, and no outside individuals or organizations will be permitted on the premises unless specifically approved and invited.

Camp Amigo Minimum Standards of Conduct:

These standards are in place to ensure the safety and well-being of all campers, counselors, and staff at Children's Burn Camp of North Florida, Inc. (Camp Amigo). All campers must read and adhere to the following rules. Violations of these rules—or any additional guidelines set during camp—may result in immediate dismissal and possible exclusion from future camps.

No alcohol or illegal substances are permitted.

No weapons of any kind, including firearms, knives, slingshots, fireworks, or any items that could cause harm.

No fighting, physically or verbally. If a conflict arises, seek assistance from a staff member.

Respect personal space—do not enter another camper’s or counselor’s living area without permission.

Do not touch or take others' belongings without their consent.

Maintain a positive environment—no degrading, insulting, or frightening behavior, materials, songs, or activities at the expense of others.

Dress appropriately—suggestive or inappropriate clothing, including revealing swimwear, is not allowed.

Have fun! Smile, laugh often, and enjoy your camp experience.

I understand that failure to follow these rules may result in being sent home early and possible exclusion from future camps.

Camp Amigo Policies:

Alcohol: The possession or consumption of alcohol by anyone, regardless of location, is strictly prohibited.

Tobacco: Campers are not permitted to use tobacco products.

Illegal Drugs & Weapons: The possession of illegal substances or weapons will not be tolerated.

Camp Boundaries: Campers must remain in designated areas and stay with their counselors at all times.

Curfew: Campers must be in their designated rooms at lights-out.

Cabin Assignments: Male campers are not permitted in female cabins, and female campers are not permitted in male cabins. Cabins must be kept clean and treated with respect. Air conditioning settings must not be adjusted.

Privacy: Respect the privacy of campers and counselors. Avoid comments or actions that could embarrass or make others uncomfortable, including remarks about weight, speech, gender, race, religion, or other personal attributes. While this is a communal setting, personal space and dignity should always be upheld.

Physical Contact: Never touch a camper or counselor in a way that could be perceived as inappropriate or that makes them uncomfortable.

Room Raiding: Raiding rooms is strictly prohibited. While it may seem like fun, it often leads to damage, loss of personal belongings, and unnecessary disruptions.

Punctuality: While camp has a relaxed schedule, there are times when punctuality is expected. Please be on time for scheduled activities and meetings.

By adhering to these policies, we can ensure a safe, respectful, and enjoyable experience for all campers and staff.

Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor treatment, x-ray examination for the named camper. In the event of an emergency or accidental injury, I understand that every attempt will be made to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Children's Burn Camp of North Florida Inc. (Camp Amigo) representatives, including Directors and Counselors, to provide the needed emergency treatment prior to the child’s admission to a medical facility, if needed.

Release authorized on the dates and/or duration of the camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Parent/Guardian Acknowledgement

BY ACKNOWLEDGING AND SIGNING BELOW, I AM GIVING PERMISSION FOR MY CHILD TO ATTEND CAMP AMIGO FROM JUNE 28-JULY 3, 2025. I UNDERSTAND THAT INAPPROPRIATE BEHAVIOR BY MY CHILD WILL RESULT IN HIM/HER BEING SENT HOME EARLY AT MY EXPENSE.

Signature

Date

Camper Acknowledgement

BY ACKNOWLEDGING AND SIGNING BELOW, I HAVE COMPLETED THE CAMPER REGISTRATION AND HAVE READ AND UNDERSTAND THE RULES FOR MY CONDUCT AT CAMP. I WILL TAKE RESPONSIBILITY FOR MY ACTIONS AND CONDUCT MYSELF IN A MANNER THAT ENSURES MY WELL-BEING. I WILL EXERCISE GOOD JUDGEMENT IN ALL MY ACTIONS AND I WILL FOLLOW THE RULES AND COOPERATE WITH THE CAMP STAFF BECAUSE THEY ARE THERE FOR MY SAFETY. I UNDERSTAND THAT IF I DO NOT FOLLOW THE RULES I MAY BE SENT HOME EARLY AND MAY NOT GET TO COME TO CAMP NEXT YEAR.

Signature

Date

Camp Amigo Registration