2018 9th and 10th Grade Camp Registration

Camper's Name *

Camper's Name

Please provide your camper's full legal name. Since your camper will be entering 9th or 10th grade next year, he or she will be attending 9th and 10th Grade Camp from Sunday, June 10 – Saturday, June 16.

First Name

Last Name

Camper’s Date of Birth *

Camper’s Date of Birth

YYYY

Camper's Sex *

Camper's Mailing Address *

Camper's Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper's Parent/Legal Guardian *

Camper's Parent/Legal Guardian

Please provide the full legal name of this camper's parent or legal guardian.

First Name

Last Name

Parent/Legal Guardian Phone Number *

Parent/Legal Guardian Phone Number

(###)

###

####

Parent/Legal Guardian Email *

Who should be contacted in case of an emergency? *

Emergency contact (if other)

If someone other than the parent/legal guardian is the camper's emergency contact, please give his or her full name and phone number here.

Please tell us about the camper's health: *

Does the camper have any dietary restrictions, allergies, or restrictions on activities? If so, please describe them here.

If camper takes medications of any kind:

Please provide here a list of medications with instructions as to the method and dosage for administering them. Medications must be turned over to camp staff upon arrival.

Camper's Health Insurance Provider *

Please give the name of the camper's health insurance provider.

Camper's Health Insurance Policy Number *

Transportation Disclaimer *

I understand that I have registered my camper after the May 15th ride deadline and that I am responsible for my camper's transportation to and from camp.

Cost of Camp *

The cost of 9th and 10th grade camp is $150. We want everyone to come to camp. No one should feel that he or she can not come to camp because he or she does not have the money. The Diocese subsidizes the operations and staffing of its camps to keep the camper fees minimal. Please select the payment option that best describes your situation. If you can contribute some of the cost of camp or do not need a scholarship, instructions for how to pay the registration fee will be included in the registration confirmation.

Further Information

If you need to provide any further information that relates to the camper that has not been addressed on this form, please provide it in the area below.

Camper Behavior Expectations *

No drugs, tobacco, or anything that can be considered a weapon are to be brought to camp. Because camp is a place of spiritual community and renewal, we will ask campers to turn in all electronics, including cell phones, mp3 players, and e-readers, so they can be present at camp. We will also insist that campers refrain from inappropriate sexual or violent behavior while at camp. And, of course, campers are to be respectful of everything and everyone at camp.

I, as the parent or guardian, have read, understood, and fully accept the Camper Behavior Expectations and agree to communicate them to the best of my ability to my child.

Parent/Guardian Release *

By selecting the box below, you as the parent or guardian affirm: the health history for this child is correct to the best of my knowledge. This child has permission to attend camp and engage in all activities, except as noted. If I cannot be reached in an emergency, I hearby give permission to the physician selected by the Camp Director or Nurse to hospitalize, secure treatment, and to order injections, anesthesia, or surgery for my child. I further understand that completion of this registration grants permission to use photos of my child, taken at camp, for publicity purposes.

I, the parent or guardian, have read, understood, and provide my full permission for the above stated release.