Elementary Camp (July 8-12, 2019)
Camper Information
Camper Name
*
First Name
Last Name
Gender
*
Male
Female
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
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11
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13
14
15
16
17
18
19
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25
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27
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
The camper will be entering what grade the following school year.
*
5th
6th
Has this camper attended Camp Caney before?
*
Yes
No
Local Church Affiliation
T-Shirt Size
*
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult 2X-Large
Adult 3X-Large
Roommate Request
(Limit ONE Please. We will try to honor these but there is no guarantee.)
FOR CAMPER: I agree to participate in all camp activities and to obey safety regulations and direction of the camp staff.
*
Yes
Back
Next
Parent/Legal Guardian Contact information
Parent/Legal Guardian Name
*
First Name
Last Name
Relationship
*
Primary Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Back
Next
For Parent/Guardian
I/We give full permission for our son/daughter to attend camp, participate in activities and group photo:
*
Yes
Photographs may be used in camp publicity:
*
Yes
No
I/We give permission to share contact information with other campers
*
Yes
No
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Next
Camper Health History Form
Please fill out your camper's medical information carefully and accurately.
In Case of Emergency
Parent/Legal Guardian to contact in case of emergency
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
-
Area Code
Phone Number
Cell/Alternate Phone
*
-
Area Code
Phone Number
Back
Next
Alternate Emergency Contact
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
-
Area Code
Phone Number
Cell/Alternate Phone
*
-
Area Code
Phone Number
Back
Next
General Medical History
Please fill out medical history as carefully and accurately as possible
Allergies
Please list any allergies your camper may have. If none, please type "none".
Food
*
Medicine
*
Environment
*
Other
*
Back
Next
Diet/Nutrition
This camper eats a regular diet
*
Yes
No
If you answered no, please explain.
Restrictions
Do you believe this camper can participate in all of the camping activities without restrictions?
*
Yes
No
If you answered no, please explain.
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Next
Medication
Please clearly label any medication and place in a ziploc bag with the camper's name on it.
Is there any medication this camper will need to take while at camp?
*
Yes
No
Name of medication and when it is given:
Does this camper have any allergies to any non-prescription medications?
*
Yes
No
If yes, please list the medication that the camper is allergic to.
Is it ok to give the camper over the counter medications for normal medical issues such as headache, upset stomach, nausea, and bug bites and/or stings?
*
Yes
No
Name of Family Doctor
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Back
Next
Insurance Information
Please fill out each field accurately and clearly so that we have the correct information in the event of an emergency. In the event of a medical emergency, we will take appropriate measures to ensure your child is safe and will contact you at the emergency numbers listed above.
Do we have your permission to transport this camper to the nearest emergency room and/or hospital by way of personal vehicle and/or ambulance in the event of a medical emergency?
*
Yes
No
Is this camper covered by family medical/hospital insurance?
*
Yes
No
Name of Insurance Company:
*
Policy Number:
*
Subscriber
*
First Name
Last Name
Insurance Company Phone Number:
*
-
Area Code
Phone Number
Back
Next
Payment
$300
Payment Types
*
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next
( X )
Online
$
307.00
Check
$
Free
Notice! Due to the costs of online registration a fee of $7.00 will be added to the total.
Once you "Submit Form" you will redirected to PayPal.com
Pay by Check - $300.00
Please put your camper's name in the memo line and make your checks payable to Caney Conference Center and mail them to Camp Caney, 1163 Methodist Camp Road, Minden, La. 71055. Checks can also be brought to camp with you. (This information will be emailed to you once you click "Submit Form").
By submitting this form I agree to our terms of service
*
Click here
for the Terms and Conditions.
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