2026 UTNG Day Camp Registration Form
Camper Information
Camper Name
*
First Name
Last Name
Camp Attending
*
Day Camp 1 (June 22-23)
Day Camp 2 (June 24-25)
Age By Camp
*
Shirt Size
*
Please Select
YL
AS
AM
AL
AXL
Sex
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Name(s) of Parent/Guardian(s)
*
Military Unit of Parent/Guardian(s)
*
Military Status
*
Please Select
Army Guard
Air Guard
Gold Star Families
Retired
Email
*
example@example.com
Phone Number 1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number 2
Please enter a valid phone number.
Format: (000) 000-0000.
24 Hour Emergency Contact Name
*
Full Name; Relation to Child
24 Hour Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Camper Health Information
Insurance Company
*
Policy/ID Number
*
Insurance Company's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Holder's Name
*
Primary Doctor's Name
*
Primary Doctor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies (Mark any that pertain to your child)
*
None
Food
Medicine
Environment
Other
If any, please describe what the camper is allergic to, the reaction seen, and management of reaction:
*
Does Your Child Carry an EpiPen?
Yes
No
Diet/Nutrition (Select any that pertain to your child)
*
This Camper Eats a Regular Diet
This Camper Eats a Regular Vegetarian Diet
This Camper is Lactose Intolerant
This Camper is Gluten Intolerant
Other (Please Describe)
Medication
Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Please send all medications in their original pharmacy containers with labels which show the camper’s name and how the medications should be given. Provide enough of each medication to last the entire time the camper will be at camp.
The follow medication may be administered on a needed basis to manage illness or injury. Please mark which ones may not be given to your child.
*
Acetaminophen (Tylenol)
Ibuprofen
Antibiotic Cream
Aloe
Advil/Motrin
All are okay!
We recommend campers are appropriately immunized for, at minimum, the following diseases: Tetanus, Mumps, Measles, Polio, Pertussis, and Diphtheria
Are your Camper's Immunizations up to Date?
*
Yes
No
If your Camper HAS NOT been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized (sign below)
General Health History. Please Select Any That Apply to Your Child.
*
Has had recurrent/chronic illness or injury
Had a recent illness or injury
Has asthma/wheezing/shortness of breath
Have diabetes
Has had seizures
Has had fainting or dizziness
Have hearing aids or impairment
Wear glasses, contacts, or protective eyewear
Wears orthodontic appliance
N/A
Please Explain Each Yes Answer
Mental, Emotional, Social Health. Please Select Any That Apply to Your Child.
*
Ever been treated for ADD or ADHD
Ever been treated for emotional and/or behavioral difficulties or an eating disorder
Within the past 12 months, has seen a professional to address mental and/or emotional health concerns
Had a significant life event that continues to affect the camper's life (e.g. history of abuse, death of a loved one, family change, adoption, new sibling, foster care, survived a disaster, etc.)
N/A
Please Explain Each Yes Answer
Please list and explain any activities you do not allow your child to participate in (e.g. swimming)
*
Please write any additional information that may affect your camper's ability to fully participate in the camp program
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Code of Conduct
Youth Signature. I will uphold the conduct and behavior standards.
Parent Signature. I have witnessed the pledge made by my child and will support them in carrying out the expectations outlined in the Code of Conduct. I understand if my child violates their codes of conduct, appropriate consequences will be administered to including immediate dismissal from the camp.
Complete Acknowledgment
I certify that the information filled out in this form is complete and accurate.
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Emergency Authorization
Emergency Authorization: I authorize all medical and surgical treatments, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedical for my child and waive my right to informed consent of treatment. This waiver applies only if neither parent/guardian can be reach in the case of emergency.
*
Yes
No
Media Release
Select One
*
I do not give permission for my child to be photographed or recorded
My child may be photographed/recorded, but not used on social media
My child may be photographed/recorded for internal or printed materials only
I give UTNG CYP full permission to take/create photos, videos, & media of my child
Child's Name
*
First Name
Last Name
Guardian's Name
*
First Name
Last Name
Signature
*
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By signing this, I ensure that all information is correct and that this form is complete
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