Teen Information
First Name (shown on ID)*
 Current Grade*

On a scale from 1 to 10, how adventurous are you?

Parent Information
Marital Status*
Father's Name

Mother's Name

Health & Transportation
Emergency Contact Information
Physician or Medical Facility
Parental Consent and Transportation Information
I hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately. Initialize*
I hereby give permission for my child to be transported and participate in field trips during operating hours. Details will be sent to me in advance Initialize*
Health History and Special Instructions
List any illnesses your child had within past 6 months
List any Sensitivities your child has. Any dislikes you feel we should be aware of?
Does your child have any allergies?
If yes, please list allergies
Does your child have a history of
Physical handicaps Rheumatic fever Heart problems Seizures Asthma Diabetes Other (describe)
Please describe any instructions that would be helpful in caring or for your child, or special medical information needed by the child’s care staff/provider.
Camp T-shirt
Registration Fee