Qamp Camp Youth Registration Form
These forms are required for your camper to attend camp July 19 and July 20, 2025. Send questions or concerns to qampcamp@gmail.com
Camper Information
Camper Name
*
First
Last
Nickname
Pronouns
*
Entering Grade in 2024/25
*
Please Select
8th
9th
10th
11th
12th
Other
Camper Cell Phone
*
cell phone number of camper
Camper T-Shirt Size
*
Please Select
YS
YM
YL
AS
AM
AL
AXL
AXXL
Campers Date of Birth
*
-
Month
-
Day
Year
Date
Camper Home Address
*
Street Address, City, State
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent/Guardian Information
Please provide information for the primary parent/guardian contact
Parent/Guardian First and Last Name. Cell Phone
*
First & Last Name
Phone number to call while camper is at Qamp Camp
Parent/ Guardian Address
Street Address, City, State
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Parent/Guardian #2 Name Parent/Guardian #2 Cell Phone
First & Last Name
Phone number to contact while camp is at Qamp Camp
Parent/ Guardian #2 Address
Street Address, City, State
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact Info
Emergency Contact #1
Full Name
*
First Name
Last Name
Address
Street Address, City, State
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Phone Number
Relationship to Camper
*
Emergency Contact #2
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Street
City, State, Zip
Postal / Zip Code
Primary Phone Number
*
Primary Phone Number
Relationship to Camper
*
Authorized Pickup Contacts
Who is authorized to pick up your camper besides the listed parents/guardians?
Authorized Pick Up #1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Authorized Pick Up #2
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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Allergy Health Information
Does your child have any non-life threatening food, medication or environmental allergies?
*
Yes
No
If your camper has food, medication or environmental allergies then please list them below
*
0/150
Does your camper have life-threatening allergies
yes
no
Does your camper have any life threatening allergies? If so, please explain the allergy and what needs to be done if your camper needs treatment or is exposed to the life threatening allergy?
*
Does your camper have any dietary restrictions or allergies that Qamp staff need to be aware of? Lunch and snacks will be provided for all campers.
*
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Additional Medical Information
In case of an emergency we will need the following information.
Please list any daily medications your child takes. Please include dosage.
*
Does your child require daily medication to be given while at Qamp Camp?
*
yes
no
If you indicated yes, please provide the name of the medication, dosage, and time to be given.
*
Please give medication to Qamp Camp staff upon arrival. Medication needs to be in original prescribed bottle.
Do you consent to your child receiving basic first aid treatment if required?
*
yes
no
Are there any medications you do not consent to us giving your camper? Or are there any medications your camper is allergic to? Please list them below.
*
Please indicate your consent for Qamp Camp staff to provide your camper with any of the following by clicking the box next to the item:
Antacid
Topical Antibiotics like Neosporin
Topical Antihistamine - Benadryl Gel
Oral Antihistamine - Benadryl, 1 tablet
Calamine Lotion, Topical
Cough drops
Dramamine, 1 tablet
Eye Drops (Visine) for irritated eyes
Saline solution for washing eyes
Hydrocortisone ointment, topical
Hydrogen Peroxide, topical
Alcohol wipes, topical
Insect Repellant
Pepto Bismol, 2 tablets
Sunscreen
Other
Please provide the name of your camper's pediatrician or primary care provider.
Name of PCP
Please provide the telephone number of your camper's pediatrician or primary care provider.
Phone for PCP
Please provide your camper's medical insurance information. This will be used for emergency purposes only.
*
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Additional Information
Please read all the information below. Details about location and time of Qamp will be emailed to you at a later date.
By signing here I give my child permission to attend Qamp Camp on July 19 and July 20, 2025. I also acknowledge I have completed this application to the best of my ability.
*
Sign to give consent for your child to attend Qamp Camp
Date Signed
*
-
Month
-
Day
Year
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