Form

Language Immersion Summer Programs

2018 Camper Application

Address:	Phone: +1-715-532-0201
1500 Port Arthur Road	Fax: +1-715-532-9916
Ladysmith, WI	Email: camp@northcedar.net

Camper Name

First Name Last Name Nick-Name
Camper or Contact E-mail *
Home Country *
Native Language *

Weeks Attending - English Plus

	Session 1: July 8 - 21	Session 2: July 22 - August 4	Session 3: August 5 - 18
Select 'Yes' or 'No' for each session

*Campers will not be allowed to participate in camp activities until the Camper Application and the Medical and Release Form are completed/signed by a Parent/Guardian and returned with a COPY of your medical insurance card (front and back).

*Campers will be responsible for any and all medical expenses incurred during camp.

*Space is limited. Online registration can be accessed at www.northcedar.net/camp, or email this form to camp@northcedar.net.

*Payments can be made online at www.northcedar.net/camp

*Forms can also be mailed to the above address.

*If also mailing payment, make checks payable to North Cedar Academy.
Camper's Information
Gender *
Date of Birth *

- Month - Day Year
Date
Age *
Height
Please indicate cm or ft & in
Weight
Please indicate lb or kg
Parent/Guardian Name(s) *

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian Home Phone *

- Country Code - Area Code Phone Number
Parent/Guardian Cell Phone

- Country Code - Area Code Phone Number
Parent/Guardian Work Phone

- Country Code - Area Code Phone Number
Emergency Contact Name & Relationship to Camper *
Who to contact if parent or guardian is not available.
Emergency Contact Email
Emergency Contact Home Number

- Country Code - Area Code Phone Number
Emergency Contact Mobile Number

- Country Code - Area Code Phone Number
Camper's Health and General History Statement
All fields are required below. If nothing applies, please put "NONE" in the box.

Thank you!
List any allergies, food allergies, drug reactions, or chronic medical conditions that would require special attention: *
Please include any symptoms associated with allergies/reactions/conditions.
List any medication the camper will take at camp: *
Please indicate name, dosage, & reason for medication.
Date of last tetanus shot *
Epinephrine Pen Use
Does your child use an epinephrine pen? *
Health Insurance Information

Please fill out the insurance information below.

***If you do not have insurance please write “Self Pay” in each of the boxes.
Carrier Name:
Policy Number:
Policy Holder Name:
Policy Holder Date of Birth

- Month - Day Year
Fitness to Participate: I affirm that the above camper has no physical, emotional, or mental condition that would affect or be affected by these activities of camp. If there is an activity they should not participate in, I will contact camp@northcedar.net with my child's name and applicable information.

Insurance Disclosure: I understand that neither NCA nor its insurance policy provide health insurance coverage for campers. I agree that all costs related to camper illness, or sickness, or accident will be billed to me and I will be responsible to pay these costs. I will check with my insurance provider to determine if additional insurance is needed to cover the camper while attending camp or participating in its activities.

Emergency Epinephrine Use: I allow camp Staff to administer epinephrine via epi-pen to my child in emergency situations while at camp. I hereby agree to save and hold harmless NCA and any of its employees from and against any and all losses, claims, damages, or expenses which may arise as a result of granting this request. This paragraph only pertains to those that marked "Yes" in the Epinephrine Pen Use section.

Waiver and General Release of Liability and Hold Harmless: In consideration of the camper’s opportunity to attend camp at NCA and participate in its activities, I on behalf of myself and the minor camper for whom I am the parent or guardian, waive and release NCA, its staff, board members, officers, directors, employees, volunteers and agents from all liability of any kind arising from or related to attendance at camp or participation in its activities. This is intended to be interpreted as a broad, general waiver and release. I further agree to indemnify and hold NCA, its staff, board members, officers, directors, employees, volunteers and agents harmless from liability for all claims for personal injury, death or property damage of any kind made by me, my family members, the minor camper for whom I am the parent or guardian or their successors.

In signing this document, I hereby certify that the above information is correct and give the following permissions:
- For my child to engage in all prescribed camp activities. I will communicate any restrictions or changes of form information to camp administration via email at camp@northcedar.net . I will make sure to include my child's full name in all correspondence.
- For the use of photographs and video including my son or daughter to be used in camp publicity.
- In the event I cannot be reached, I hereby give permission to the physician selected by camp staff to obtain proper medical diagnosis, hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child as named above.
Parent/Guardian Signature
Should be Empty:

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