Camper Registration Form 2026
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  • Camper Registration Form 2026

    A separate form must be filled out for each child attending camp.

  • When: July 31 - Aug. 2, 2026

    Where: Tallulah Falls, Georgia, at Camp Chattooga, adjacent to Athens Y Camp (80 miles north of Atlanta)

    Who: Children ages 6 to 16

    Cost: $25 per child

    Registration Deadline: June 30, 2026

  • Camper's Information

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Can this phone number receive texts?*
  • Has this child attended PruittCares Foundation, Inc. d/b/a Camp Cocoon in the past?*
  • Transportation TO Camp:*
  • Transportation FROM Camp:*
  • Will any other child from your household be attending camp?*

  • Deceased Loved One's Information

  • Date of Death*
     - -

  • Parent/Guardian with Whom Child Lives

    Emergency Contact
  • Format: (000) 000-0000.
  • Can this phone number receive texts?*
  • Format: (000) 000-0000.
  • Can this phone number receive texts?

  • Alternate Emergency Contact

  • Format: (000) 000-0000.
  • Can this phone number receive texts?*
  • Format: (000) 000-0000.
  • Can this phone number receive texts?

  • Camper Health Form 2026

  • Child's Date of Birth*
     - -
  • Format: (000) 000-0000.
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  • Allergies

  • Dietary Restrictions*

  • Medical Emergencies

  • Will a family member or friend be able to pick up the child immediately in case of an emergency?*

  • General Health Questions

  • Please answer the following questions as they relate to your child, providing as many details as possible in order to help our nurses provide the best care to your child during their camp experience.

  • Has your child had any recent injury or infectious disease?*
  • Does your child have a chronic or recurring illness/condition?*
  • Has your child been hospitalized in the last 18 months?*
  • Has your child had surgery in the last 18 months?*
  • Does your child have frequent headaches?*
  • Has your child ever had a head injury?*
  • Has your child ever been knocked unconscious?*
  • Does your child wear glasses, contacts, or protective eyewear?*
  • Has your child ever passed out during or after exercise?*
  • Has your child ever been dizzy during or after exercise?*
  • Has your child ever had chest pain during or after exercise?*
  • Has your child ever had seizures?*
  • Has your child ever had frequent ear infections?*
  • Does your child have an orthodontic appliance?*
  • Does your child have a history of bed wetting?*
  • Has your child ever had high blood pressure?*
  • Has your child ever been diagnosed with a heart murmur?*
  • Has your child ever had back problems?*
  • Has your child ever had problems with joints (knees, ankles, etc.)?*
  • Has your child ever had any skin problems (itching, rash, acne)?*
  • Does your child have diabetes?*
  • Does your child have asthma?*
  • Has your child had mononucleosis in the past?*
  • Does your child have problems with diarrhea/constipation?*
  • Does your child have problems with sleepwalking/night terrors?*
  • If female, has your child begun her menstrual cycle?*
  • Has your child ever had an eating disorder?*
  • Does your child have ADD/ADHD?*
  • Has your child had a TB Mantoux test?*
  • If you answered "yes" to the previous question, please enter the date of the test.
     - -
  • If your child has had a TB Mantoux test, what was the result?
  • Which of the following illnesses has your child had? (Please check all applicable answers.)*

  • PLEASE NOTE: If your child has been exposed to any communicable disease, particularly COVID-19, chicken pox, measles, or mumps 1-3 weeks prior to camp, please contact us as soon as possible.

  • Medications

  • The medical staff will store and administer any medications needed during the camp weekend. Each child should arrive at camp with a 3-day supply (ONLY) of his/her routine medications in the original pharmacy containers complete with written instructions.

  • Regular Medication*

  • Other Needs

  • Is your child allowed to get into the shallow end of the lake with lifeguards present?*

  • Emotional/Behavior Questions

  • Please answer the following questions as they relate to your child, providing as many details as possible. Indicate if the behavior was present before the death of their loved one, or if the behavior began after the death.

  •
  • Is your child being seen by a professional counselor at this time?*

  • Consent Form

  • The following consent agreement must be signed by a parent or legal guardian of the minor child in order for the child to attend PruittCares Foundation, Inc. d/b/a Camp Cocoon ("Camp Cocoon" or "Camp").

    Your signature below indicates that you acknowledge and agree to each of the following:

    1. I hereby attest that this health history and all other information contained in this registration packet is correct to the best of my knowledge, and that my child has permission to engage in all Camp activities except as noted. The staff of Camp Cocoon exercises caution in the conduct of all camp activities; however, neither they, nor Camp Cocoon, assumes responsibility for accidents, injury or illnesses suffered by its campers.

    I further understand that serious accidents occasionally occur during Camp activites, and that participants in Camp activities occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof. Knowing the risks of Camp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence, carelessness, or otherwise) might be liable to my child or to me (or to my heirs or assigns) for damages, along with each of their respective affiliates and employees. For the sake of clarify, any transportation arranged by Camp Cocoon shall be considered a "Camp activity" for all purposes hereunder.

    2. Camp Cocoon accepts no responsibility for the loss, damage or theft of property, or for personal injury.

    3. Details of my health and accident insurance coverage, if applicable, are as follows:

  • Format: (000) 000-0000.

  • 4. I recognize and understand that Camp Cocoon is operated by PruittCares Foundation, Inc., a charitable organization. My child and I are receiving all of the benefits of Camp Cocoon with minimal or no costs to us and recognize that Camp Cocoon is immune from suit under Georgia's Charitable Immunity Doctrine.

    5. In case of medical and/or surgical emergency, I authorize Camp Cocoon's medical staff to render to my child or to arrange for my child to receive any X-rays, anesthetic, medical, dental, surgical diagnosis, treatment, and hospital care which is deemed advisable by and is to be rendered under, the supervision of any physician, dentist or surgeon licensed to practice in the State of Georgia. I also grant permission for a licensed nurse to administer over-the-counter medication such as ibuprofen, acetaminophin, and antihistamine, as needed.

    6. I acknowledge that reporters, photographers, videographers and other members of the media may attend Camp Cocoon in order to increase the awareness about Camp Cocoon and its programs. I grant permission for my child to be interviewed, photographed, and filmed by any member of the media at Camp Cocoon. I understand that Camp Cocoon is not responsible for the content of the media coverage and that my child will not be paid for any media work.

    7. Camp Cocoon and its representatives have absolute permission to use my child's image in a photograph or video or my child's artwork that pertains to the lawful programs and activities of the Camp.

  • Date of Signature*
     - -
  • Signer's Relationship to Camper*
  • Should be Empty: