Northeast Foursquare Youth CampJuly 2 - 6, 2012

REGISTRATION FORM FOR CAMPERS(Entering 6th - 12th Grade)

PART TWO (MEDICATIONS)

Last Name______________________________________ First Name _______________________________________ MI ______

Street Address________________________________ City _____________________________ State ________ Zip ____________

Phone Number _______________________________________ Cell Number __________________________________________

Date of Birth _______/_______/__________ Gender ____ Fall 2012 Grade _____ Church _____________________________________

Emergency Contact: Name (first & last) ___________________________________ Relationship to Camper _________________________

Home Phone (__________)____________________ Cell Phone (__________)____________________Health Insurance Company ________________________________ Health Insurance Subscriber _________________________________

Health Insurance Phone # (__________)____________________ Policy# _______________________________________________

Primary Care Doctor ________________________________________ Phone Number (________) ___________________________

Please attach a copy of both sides of your insurance card

Medical Information:Medication or medical problems (Use back of form/separate page if needed) _______________________________________________________________________________________________________________________________________________________Allergies (What are they & what happens) ____________________________________________________________________________________________________________________________________________________________________________List anything else you think we should be aware of ____________________________________________________________________Diet /Activity restrictions ______________________________________________________________________________________________________________________________________________________________________________________Date of last Tetanus shot _________________ Date of Meningococcal Meningitis (MCV4) ______________ Date of MMR Booster _____________Have you ever had a flu shot? ___ Yes ___ No Date of last flu shot _________________

If your camper has not been fully immunized, please sign the following statement: I understand and accept the risk from my camper not being fully immunized.Signature of Parent/Guardian ___________________________________________________ Date ____________________Relationship to camper ______________________________________

PART ONE (CAMPER INFORMATION)

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Campers with prescription medications must have a doctor’s signature on file before the camp nurse may dispense medications. All medications MUST come in their ORIGINAL package, this includes over-the-counter medications. “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. We require original pharmacy containers with labels, which show the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. The following non-prescription medications are commonly stocked in camp Health Centers and are used on an as needed basis to manage illness and injury. Please cross out those items the camper should not be given.

Northeast Foursquare Youth CampJuly 2 - 6, 2012

REGISTRATION FORM FOR CAMPERS(Entering 6th - 12th Grade)

REQUIRED ONLY FOR PRESCRIPTION MEDICATIONSAttach a letter if additional space is needed.

Name of medication _________________________________________ Dosage _________________________________________

Condition Requiring Medication __________________________________ Times Normally Taken ________________________________

Name of medication _________________________________________ Dosage _________________________________________

Condition Requiring Medication __________________________________ Times Normally Taken ________________________________

Name of medication _________________________________________ Dosage _________________________________________

Condition Requiring Medication __________________________________ Times Normally Taken ________________________________

PART TWO (MEDICATIONS CONTINUED)

PART FOUR (PASTOR SIGNATURE)I, ___________________________________________________, recommend this camper, as one who will cooperate with the staff, rules and camp program.

__________________________________________________________________________________________________Senior Pastor Signature Date

THIS REGISTRATION FORM IS NOT VALID WITHOUT THE FOLLOWING TWO SIGNATURES:CAMPER Declaration: I will fully cooperate with the staff, rules, Camper Guidelines and program established for the camp so as not to discredit my parents, my church or myself. I understand that behaving in an unruly manner can result in being dismissed from camp. I agree to fully cooperate with the camp directors and other leaders.

Camper Signature ______________________________________________ Date _____/______/20____

PARENTAL Release: My child will fully cooperate with the staff, rules and program of the camp. I understand that I am responsible for my child's actions and will be held financially responsible for any damage done by my child. I will pay for any and all repairs incurred by such damage. I acknowledge that many of the camp/sport activities contain inherent risk of injury. It is understood that in the event of an injury the camp officials will make a conscientious effort to locate contacts listed on the form before any action is taken. I understand that my own insurance is primary with regard to payment of medical providers; our church activities insurance is secondary. I hereby consent to my child participating in all camp activities. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with the camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. I consent to any treatment deemed advisable in an emergency by an EMT, nurse, medical doctor or other first-aid personnel. I certify that all of my child's immunizations are up-to-date unless otherwise noted. I give permission for the medications as listed on the previous page to be given to my camper as needed.

I consent that any photographs or videos taken at camp of my child may be used in promotional materials or posted on the District website or for the use of a camp video, unless a letter requesting otherwise is submitted with this application.

Parent Signature _____________________________________________ Date _____/_____/20_____

PART THREE (CAMPER/PARENT SIGNATURE)

Physician’s Signature: Required for prescription medications for those under 18

Signature ____________________________________________________________________ Date _____________________

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Northeast Foursquare Youth CampJuly 2 - 6, 2012

REGISTRATION FORM FOR CAMPERS(Entering 6th - 12th Grade)

Return the completed forms to your church:1) ____ Total Registration Fee $189Add $20 after May 21, 2012Make all checks payable to your church2) ____ Completed Registration FormRegistrations are non-refundable, but are transferable within your church. Please notify your church if this is necessary.

PART SIX (CHECKLIST)

For a list of what to pack for camp, etc. Visit our website

at: www.northeast.foursquare.org

For the safety of all campers, each participant is required to follow the basic guidelines listed as well as the instructions given to them during camp.

• The schedule of events is to be followed.• No camper is permitted to leave the campgrounds or its designated areas without

prior permission from the camp director.• Smoking, matches, fireworks are not permitted.• Intoxicants of any kind and weapons are not permitted.• All prescription medications and over the counter medications are to be given to the

camp nurse upon arrival. Medications must be in their original containers. See part one of form for more details.

• Boys are not permitted in the girls’ rooms and girls are not permitted in the boys’ rooms.

• Clothing should remain modest and not promote unfavorable behavior such as alcohol consumption, drugs, violence or sinful behavior. Girls are asked to wear a 1-piece swimsuit.

• The person responsible for damage due to vandalism is also responsible to pay for repairs.

• Electronic devices such as: iPods, mp3 players, handheld game devices, cell phone use, etc. are NOT permitted.

PART FIVE (CAMPER GUIDELINES)