Camper Information We recommend a parent’s email address be used. You will be receiving important information through this email address.

*First Name

*Last Name

*Email

Preferred Name

*Address 1

Address 2

*City

*State

*Zip

*Phone

*Gender

Female ($55)

Male ($55)

Female: There are only 5 available

Male: There are only 8 available

*Grade entering this fall

*Birthdate Enter month, day, and year in following manner (--/--/--)

Church Name Please list your home church

Contact Information

*Mother/Guardian Full Name

*Mother/Guardian Phone Number

*Father/Guardian Full Name

*Father/Guardian Phone Number

Camper lives with

*Emergency Contact Full Name This person will be called only if parents can't be reached.

*Emergency Contact Phone Number

Health/Medical Information

*Help us understand camper's needs.

Check all that apply.

Other health concerns.

Check all that apply.

Has difficulty walking up and down stairs

Has been recently exposed to a contagious disease

Has tubes in the ear

Has a skin disease

Has experienced unusual stress or trauma

Has a condition requiring restricted activities or special assistance

Please explain checked boxes above and add any additional needs not mentioned

*What medication will camper take while at camp? Please list all medications, dosage, and dosage instructions

*Please list any dietary needs/food allergies you may have.

Immunizations

*Tdap (Tetanus, Diphtheria, Pertussis) (Month/Year)

Insurance/Physician Information

Family medical insurance company

Name of insured

Policy number

Group number

Physician's name

Physician's phone number

Permission/Agreements

*Health Emergency Release I understand that camp staff need to know pertinent information about the camper’s mental and physical health. Therefore, I have disclosed all information that could jeopardize the camper’s health and safety or the safety of others. Failure to disclose information could require my child to be sent home from camp. I give permission to the camp to provide routine health care, administer prescribed and over-the-counter medications and seek emergency medical treatment including ordering x-rays and routine tests. I give permission to the camp to arrange necessary related transportation. I agree to the release of any records necessary for insurance purposes. In the event I cannot be reached (or cannot respond if an adult camper) in case of an emergency, I give permission to the physician(s) selected by the camp staff to secure and administer proper treatment, including hospitalization, for the above-named person and to release information regarding said medical treatment to camp staff.

Yes

No

*Medication Release I hereby request that the registrant receive the above medication(s) as noted and that the nurse or another adult camp leader administer the medication. I understand it is my responsibility to furnish this medication and proper instructions for administering the same. I further understand and agree that on behalf of myself and the person named in this registration, I do hereby waive and release any action, cause of action, or claim of liability for any loss, damages, accident, or injury of any kind against the Kansas West Annual Conference and against any nurse or adult camp leader arising from the administration of medication, including, but not limited to, any claim that medication was negligently administered, and I agree to indemnify, protect, and hold harmless such persons and the Kansas West Annual Conference from any and all such claims.

Yes

No

*Photo Permission Photos taken at camp may be used by the Kansas West Annual Conference for camp promotions. If you would rather not have photos of your child used for this purpose, please check NO.

Yes

No

*Participation Agreement The registrant agrees to participate fully in the activities for which I have registered, obeying safety regulations and directions of all camping staff.

Yes

No

H404B Little Explorers Day Camp June 21