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Emergency Contact Information This person will be contacted if the Parent or Guardian is unavailable. Other than the 2 guardians listed above, and the
emergency contact, please list other adults who may pick up this camper in the Release of Minors area below.
Name _______________________________ Relationship to Camper _________________ Phone ___________________
2019 Registration Form
Relationship to Camper ______________________
Title _______
First Name ________________________________
Last Name ________________________________
Email ____________________________________
Cell Phone _____________________
Work Phone ___________________
Home Phone ___________________
Relationship to Camper ______________________
Title _______
First Name ________________________________
Last Name ________________________________
Email ____________________________________
Cell Phone _____________________
Work Phone ___________________
Home Phone ___________________
Please include a $50 NONREFUNDABLE DEPOSIT for each
camp.
Please complete a separate form for each camper.
Please Print Legibly
Parent/Guardian Information
Camper Information
For Office Use Only
First Name ___________________________________ Last Name ___________________________________
Gender: Male Female Date of Birth____/____/______ Age: _____ Grade in September 2019:______
Home Address_________________________________ City ______________________ State_____ Zip code __________
T-Shirt Size:
Youth/Child: Small Medium Large X-Large
Adult: Small Medium Large X-Large
Release of Minors All Campers are released at the end of camp to their parent/guardian (listed above),
emergency contact or one of the individuals below. NO EXCEPTIONS. Please be advised that photo identification and camper pickup ID card must be provided at time of pickup.
Name _______________________________ Relationship to Camper _________________ Phone ___________________
Name _______________________________ Relation ship to Camper _________________ Phone ___________________
Name _______________________________ Relation ship to Camper _________________ Phone ___________________
Parent/Guardian Signature _________________________________________________ Date___________________
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2019 Registration Form
Additional Information
Cabin Buddy* – for overnight Camps ONLY
*This is a REQUEST and not a guarantee
1st Choice _______________________________________ 2nd Choice _______________________________________
Housing Information- for overnight Camps ONLY
Cabin Covered Wagon (Wagons are not available for High School Camp)
DAY CAMPS- Ages 5-9 Regular Care– 8:30-3:30 Extended Care– 7:45-5:30 Spring Break Camp- March 25-29 Regular Care $155 Extended Care $175 Day Camp 1-July 8-12 Regular Care $235 Extended Care $265 Day Camp 2-August 5-9 Regular Care $235 Extended Care $265 Day Camp 3-August 26-30 Regular Care $235 Extended Care $265
OVERNIGHT CAMPS Grades 1-5 Elementary Overnight
EON– June19-21 $205
Grades 3-5 Junior Overnight
JR1– June 30-July 3 $219
JR2– August 18-22 $284
Grades 5-7 Tween Overnight
TW1– July 14-19 $354
TW2– August 11-16 $354
Grades 6-8 Middle School Overnight
MS1– June 23-28 $379
MS2– July 28-August 2 $379
Grades 9-12 High School Overnight
HS– July 21-26 $389
Camp Information Please select which camp(s) you would like to register for.
Parent /Custodial Issues
Check here if there are any unresolved legal parent/custodial issues that Camp Harlow needs to be aware of. NOTE: If you have a ‘working’ parenting plant, that does not necessarily constitute marking this box. Marking this box will initi-ate a request for more documentation. Please call the Camp Harlow office with any questions 541.683.5416.
If you marked YES, please explain:_____________________________________________________________________
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2019 Registration Form Additional Options
The Camp Store and Café are available for all ages and are an additional opportunity for campers to enjoy while they
attend Camp. The students attending our Tween, Middle School, and High School camps have the opportunity to add
paintball to their experience for an additional fee.
Camp Store & Cafe— Please select all that you desire
$10 $15 $20 $30 Donate the remaining Camp Store Balance to the Scholarship Program
Paintball— Please the number of Games you would like to play—(Eligible camps are Tween, Middle & High School)
1 Game $20
Media
Team or Cabin Photo $8
Camp Video, Online Delivery $15
Combo– Cabin Photo and Video $20
Help Sponsor another Camper— Please select the all that you desire
$5 $10 $25 Other $___________
Total (Including the camp and any options selected above) $________
Payment Information Minimum $50.00 deposit is required per camp. (This is NONREFUNDABLE and is a part of the total camp fee)
Total enclosed $____________
Payment method: Check Cash Visa MasterCard Other (AMEX/Discover)
Check Number ___________
Please Charge my credit Card:
Number ___________________________
Expiration Date ______/______
CVV ________
Billing Zip Code ___________
Print Name _______________________
Signature __________________________
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2019 Registration Form Camper Information
Does your Camper have any special interests/activities that he/she especially enjoys?
____________________________________________________________________________________________________
To help set your camper up for success, it here any additional information that would be pertinent for the counseling staff
to know about your camper? Please let us know below:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
How did you hear about Camp Harlow? ___________________________________________________________________
Medical Information
Does your camper have any known Allergies? Yes No
Please list below any known allergies and list treatment and details for them.
Allergies:
______________________________________________________________________________
______________________________________________________________________________
Details and Treatment:
______________________________________________________________________________
______________________________________________________________________________
Does your Camper have any Dietary Restrictions? Yes No
Please list below any known allergies and list treatment and details for them.
______________________________________________________________________________
______________________________________________________________________________
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2019 Registration Form Instructions for Medications at Camp Harlow
All Medication must be turned in to the nurse at registration. DO NOT pack any medication in your camper’s luggage.
All Medication must be in its ORIGINAL containers with the Camper’s name and instructions. (You may ask your phar-
macist for an extra container)
Please bring exact number doses plus one for time at camp. *No need to bring acetaminophen, ibuprofen or aspirin.
Sample medications will be accepted with a doctor’s note authorizing the medication with dosage and instructions.
All medication is kept in the Nurse’s station and is administered there.
Campers who need emergency inhalers or epi-pens may carry them. You may choose to leave these with the nurse. If
not, you must leave a backup supply at the Nurse’s station, one with camper, one with nurse.
Over the counter medications are not accepted. Please see the list on the following page of the over the counter medi-
cations that are on hand.
Camp Harlow must be made aware of any special needs or considerations at minimum of 2 weeks prior to the camp .
Medication Information
Name of Medication Dosage Time Reason for Medication
Please list any current medical conditions or concerns, any recent injury, or limitations to activities at Camp
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Over the Counter Medications Please mark any medications that you DO NOT want your child to have.
The Camp Harlow consulting physician has issued standing orders permitting the dispensing of common over the counter
medications. These will be dispensed as needed. DO NOT send these medications with your camper.
Also, please mark any medication that you DO NOT want your child to have.
2019 Registration Form Doctor and Insurance Information
This person will be contacted if the Parent/Guardian or Emergency Contact are not available
Family Doctor Name _____________________________________________________Phone Number ________________
Health Insurance Company _____________________________________________________________________________
Date of last Tetanus Shot _____/_____/_____ (A tetanus shot is required)
Non-aspirin pain reliever (Tylenol or generic)
Ibuprofen (Advil or Motrin)
Antacid (Mylanta or Tums)
Antihistamine (Bendadryl, Loratadine, Cetirizine)
Cough Syrup (Robitussin DM)
Decongestant (Sudafed PE)
Imodium (for Diarrhea)
Pepto Bismol
Melatonin
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Health History Information Please review the following list and note if they have any of the following
medical conditions and how they are treated.
2019 Registration Form
Conditions No Yes Un-
known Details
Asthma
Diabetes
Physical Needs or
Challenges
Developmental Delays
Behavioral Concerns
Emotional Concerns
Social Concerns, or con-
cerns with interactions
Needs Specific Redirection
Activity Restrictions
Special Assistance
Other Medical Challenges
Other Needs
Do you require our Medical staff to follow up with you? Yes No
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Parental Release
2019 Registration Form
AUTHORIZATION OF TREATMENT
I, the parent or legal guardian of the listed camper, hereby give permission to Camp Harlow to
administer medication as previously listed. I understand that it is my responsibility to provide pre-
scription medication in original pharmacy containers or as labeled physician samples.
I understand that if my camper requires medical attention in additional to the described above,
that Camp Harlow will attempt to contact me first. If I am unavailable, I authorize Camp Harlow to
contact my camper’s physician. If neither I nor my child’s physician. If neither I nor my child’s phy-
sician is available, I authorize Camp Harlow and First Baptist Church to order X-Rays, routine tests,
and treatments ; to release any records necessary for insurance purposes; and to provide or ar-
range transportation for my camper to a nearby clinic or hospital. I will hold harmless Camp Har-
low, its staff and the First Baptist Church of Eugene, and its pastors from any claim of liability aris-
ing from attending camp.
PHOTO/VIDEO RELEASE INFORMATION
During our camp sessions, the Camp Harlow Staff takes photo and videos for cabin or team pho-
tos, daily videos, slide shows and promotional purposes. If there are reasons that your child
should not be photographed or on video, please contact the Camp Harlow Office at 541.683.5416
at your earliest convenience.
ACTIVITIES & TRAVEL RELEASE
I, the parent or legal guardian of the previously listed camper, hereby give permission for my
camper to travel to and participate in offsite Camp Harlow Middle School or High School activities
such as Breakfast on the Butte, Service Projects, and Lake Day.
I, the parent or legal guardian of the previously listed camper, hereby give permission for my
camper to participate in onsite Camp Harlow activities such as; Zipline, Big Swing, Challenge
Course, Intensity Bridge, Flying Squirrel, Canoes, Fort Hawk, Inflatables, Rockwall, Archery, Swim-
ming Pool, Go Carts, Fire Truck Rides, and Train Rides.
I, the parent or legal guardian of the previously listed camper, hereby give permission for my
camper to ride and or be around horses at Camp Harlow.
________ INITIALS ________ INITIALS ________ INITIALS ________ INITIALS ________ INITIALS ________ INITIALS
Signature of Parent/Guardian __________________________________
Printed name of Parent/Guardian _______________________________ Date _____________
NOTE: by initialing and signing above, you acknowledge that you have read and agreed to each item.