Camper Registration

NC WEST KIDS' CAMP REGISTRATION!

Important Camp Information:
- NC West Kids' Camp will be held at Victory Mountain Camp in Sophia, NC
- Register by June 28th to avoid the $50 late fee.
Next Steps:
- Parent/Guardian: Once you submit this registration form, you will receive an email with confirmation of the registration. A $50 deposit is due at the time of registration. Turn in all funds to your church leader (checks should be made to your local church).
- Church leader: Collect all deposits and mail one church check (made payable to "NC West Kids Camp") by the END OF JUNE to avoid paying late fees. Checks can be mailed to:
Doreen Garmon

119 N. Bunker Hill Road

Colfax, NC 27235
Camp Dates:

Junior Camp (those completing grades Kindergarten and 1st) -

Sunday, July 26 - Tuesday, July 28

Cost: $175 ($225 after 6/28)

Senior Camp (those completing grades 2nd,3rd,4th,&5th) -

Tuesday, July 23 - Friday, July 31

Cost: $250 ($300 after 6/28)
Junior Camp (Completed K-1st)Senior Camp (Completed 2nd-5th)
Name of Church with which you are attending:*
If other, please list church:*
Please list the email address of your children's pastor or leader coordinating camp (children's pastor, senior pastor, camp coordinator)*
example@example.com
Camper Information:
Camper's Name*

First NameLast Name
Grade Completing*
Age*
MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information

Parent/Guardian Information is required for at least one adult. The form requires either Father/Guardian information OR Mother/Guardian information. Information for both can be listed.
Father's Name (or Guardian)

First NameLast Name
Mother's Name (or Guardian)

First NameLast Name
Parent/Guardian Email Address (Camp information will be sent to THIS email address) *
Father's CELL Number*

Area CodePhone Number
Mother's CELL Number*

Area CodePhone Number
Home Number*

Area CodePhone Number
Additional Emergency Contact (other than parents/guardians)
Relationship to Camper*
Emergency Contact's Name*

First NameLast Name
Emergency Contact's Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
YESNO
Please mark your child's TSHIRT size. *
SHIRTS ARE PROVIDED IN COST OF CAMP
We want to make you aware that pictures will likely be taken of your child while at camp. If there is a legal or confidentiality issue involving your child/family and your child's picture should not be shown on the internet, please let us know below. Thank you!
YESNO
If yes, please explain:*
My child may NOT be released to the following people (custody, etc.)
We recognize changes may occur during the week of camp. If someone other than the person your child is expecting needs to pick him/her up, please send a signed note with that person.

******** HEALTH INFORMATION FOR THE NURSE ********

Type "N/A" if the question is not applicable.
Allergies - food, medications, bees, etc.
Typical Reaction to the allergy
Treatment for the allergy
****ALL medication must be brought to camp in a bottle that is completely LABELED by a pharmacist. ALL medication must be turned into the camp nurse upon arrival at registration. (This includes over the counter medication). Campers are not allowed to self medicate at camp and cabin leaders are not allowed to adminster medication.***
List all medications your child takes including name, dosage, schedule, and reason for taking
YESNO
Date of Last Tetanus Shot
Please list any medical and/or behavioral information that camp staff should be aware of:
Physician's Name
Physician's Phone Number

Area CodePhone Number
Health Insurance Company
Group Number
Policy Number
Thank you so much for this information. You and God have entrusted your child into our care, and we take that very seriously. Thank you for enabling us to do the best that we can.
SIGNATURE AND AUTHORIZATIONS
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the NC West Kids Camp and its affiliates including Directors, Cabin Leaders, and other leaders of the camp to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
YESNO
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by NC West Kids Camp during the selected camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless NC West Kids Camp and all its respective leaders, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against NC West Kids Camp and the NC West District of the Wesleyan Church, including all leaders and affiliates, all participants, sponsoring agencies, and, if applicable, owners and lessors of premises used to conduct the event. I realize there is a risk of being injured that is inherent in all camp activities.
YESNO
I authorize that I am the parent and/or legal guardian of the camper being registered and I certify that all the information given on the registration form and the medical form is true to the best of my knowledge. I also certify that I have read the "Medical Release and Authorization Statement" as well as the "Informed Consent and Acknowledgement" Statement and have checked my appropriate response to each.

Electronic signature required below.
Parent/Guardian Signature*
Clicking the "SUBMIT" button below serves as your online signature for this registration.

Once you click "SUBMIT" you will receive an email from NC West Kids' Camp verifying registration. Don't forget to turn your $50 deposit (checks made payable to your local church) in to your leader!

Thank you!
FOR OFFICE USE ONLY
*****FOR OFFICE USE ONLY*****

CABIN ______________________

AMOUNT PAID ________________

CHECK NUMBER ______________

NAME ON CHECK _____________

BALANCE DUE ________________
CABIN _______________
*****FOR OFFICE USE ONLY*****

Prn ________________________ ________________________

___________________________ ________________________

___________________________ ________________________

___________________________ ________________________

____AM ____LUNCH ____SUPPER ____AS NEEDED ____QHS
Should be Empty:

SIGNATURE AND AUTHORIZATIONS

FOR OFFICE USE ONLY