Camp

Episcopal Youth Camp 2018

Camper Registration, health form, and permission release
Parent/Guardian Name *

First Name Last Name
In Michigan? *
Will you be in Michigan during camp?

Address *

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

Cell Phone Number *

Area Code Phone Number
Receive text updates *

yes no
Alternate Phone Number

Area Code Phone Number
Email *
example@example.com
Receive email updates *

yes no
If you'd like to add a second parent, please include all information that is different from above.
Second Parent/Guardian

First Name Last Name
In Michigan?
Will you be in Michigan during camp?

Address

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

Cell Phone Number

Area Code Phone Number
Receive text updates

yes no
Alternate Phone Number

Area Code Phone Number
Email
example@example.com
Receive email updates

yes no

Emergency Contact Information
These must be people with a different phone number from the parents/guardians and in Michigan during camp.
Emergency Contact 1 - Name *

First Name Last Name
EC 1 - Phone Number *

Area Code Phone Number
Emergency Contact 2 - Name

First Name Last Name
EC 2 - Phone Number

Area Code Phone Number

General Information
Do you allow the camp to publish photos? *

yes no
What parish do you attend? *
(please include Parish Name, Town)
How will you be paying for camp? (check all that apply) *

online by credit card mailing in check/money order parish paying friends/family Seeking financial assistance from camp

Family Medical Information
Insurance Carrier *
Insurance Group Number *
Doctor's Name

First Name Last Name
Doctor's Phone Number

Area Code Phone Number
In some instances it may be helpful for the cabin counselors or other staff members to know some of the information on the medical record. By checking yes, we will still keep information as confidential as possible.

Please check one of the options below.
What medical information may be shared? *

Information the Nurse and Camp Director deem helpful may be shared No information may be shared unless an emergency occurs

Camper Information
Camper *

First Name Last Name
T-shirt size *
Nickname
What name does the camper like to be called?
At the end of each week of camp, we like to give out a list of all participants. The list includes name, parish, cabin, and a way to contact them. Please put the best contact information below (email address or phone number - or "none" if you wish not to have that listed).
Email or phone for End of Week List *
Phone or email address
Which Camp *

Senior Camp Middle Camp Junior Camp CiT (Counselor in Training) LiT (Leader in Training)
Grade (fall 2018) *
Male or Female *
Camper Phone Number

Area Code Phone Number
Receive text updates

yes no
Camper Email
example@example.com
Receive email updates

yes no

Camper Check-out Information
Non-Release Names

All campers must be signed out at the end of each session.

Because we encourage carpooling, we allow campers to be released to adults who are not their parents. If there is someone your child MAY NOT be released to, please list the name(s) below.

If there is someone who is legally not allowed to have contact with your child, please alert the Camp Director.
Non-Release Names
Early or mid-session Release
We know that sometimes campers need to leave a bit early, or even mid-session and return. Please help us plan by listing the dates/times below, and letting the cabin counselor know.
Early or Mid-Session Release
Would you like to add another camper? *

yes no

Camper 2
Camper 2 - Full Name

First Name Last Name
T-shirt size
Nickname
What name does the camper like to be called?
Email or phone for End of Week List
Phone or email address
Which Camp

Senior Camp Middle Camp Junior Camp CiT (Counselor in Training) LiT (Leader in Training)
Grade (fall 2018)
Male or Female
Camper Phone Number

Area Code Phone Number
Receive text updates

yes no
Camper 2 Email
example@example.com
Receive email updates

yes no

Camper 2 Check-out Information
Non-Release Names
If there is someone your child MAY NOT be released to, please list the name(s)
Early or Mid-Session Release
If your child needs to leave a bit early, or even mid-session and return, please list the dates/times below, and let the cabin counselor know when you drop off.
Would you like to add another camper?

yes no

Camper 3
Camper

First Name Last Name
T-shirt size
Nickname
What name does the camper like to be called?
Email or phone for End of Week List
Phone or email address
Which Camp

Senior Camp Middle Camp Junior Camp CiT (Counselor in Training) LiT (Leader in Training)
Grade (fall 2018)
Male or Female
Camper Phone Number

Area Code Phone Number
Receive text updates

yes no
Camper 3 Email
example@example.com
Receive email updates

yes no

Camper 3 Check-out Information
Non-Release Names
If there is someone your child MAY NOT be released to, please list the name(s)
Early or Mid-Session Release
If your child needs to leave a bit early, or even mid-session and return, please list the dates/times below, and let the cabin counselor know when you drop off.

Permissions
As a parent/guardian, I hereby give permission for the designated child to attend the Episcopal Youth Camp in the Diocese of Western Michigan and to participate in all the activities except as noted above and give permission for my child to be transported in cases of emergency or for a planned program. I understand that my child must follow the rules set forth by the Diocese of Western Michigan. If dismissal because of a disciplinary problem occurs, transportation will be provided by or paid by the person or a parent and any registration fees will not be reimbursed. A copy of the incident report and the course of action will be kept in the camp files, be sent to the person’s home rector or sponsoring clergy person and be sent to the Bishop.

This health history is correct and complete as far as I know. I give permission to the camp to provide routine health care, administer medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician/nurse selected by the camp to secure and administer treatment, including hospitalization, for the person named above. Information in this completed form may be printed and photocopied as necessary.

I agree to hold the Diocese of Western Michigan and any associated agencies and persons harmless and waive any claims for payment of accident, injury, disability or damages to the person or property of the aforementioned child arising out of or connected with his/her participation in any activity related to his/her participation in the aforementioned activity.
I agree to the above statements *

yes
Electronic Signature *
Please type your full legal name to serve as your electronic signature
Date *

Month Day Year
Please select today's date Date Picker Icon
Should be Empty:

Episcopal Youth Camp 2018

Emergency Contact Information

General Information

Family Medical Information

Camper Information

Camper Medical Information

Camper Medication

Medication

Camper Check-out Information

Camper 2

Camper 2 Medical Information

Camper 2 Medication

Camper 2 Check-out Information

Camper 3

Camper 3 Medical Information

Camper 3 Medication

Camper 3 Check-out Information

Permissions