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Camp Jr Form
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Indicates required field
Child's Name
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First
Last
Child's Age
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Gender
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Male
Female
Grade entering Fall 2018:
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EMAIL
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Check the applicable catagory:
Select Shirt Size for Child
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Small (youth)
Medium Youth
Large Youth
XLarge Youth
Small Adult
Medium Adult
Mother's Name
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First
Last
Phone Number
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Father's Name
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First
Last
Phone Number
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Emergency Contact Name
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First
Last
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Relationship
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Phone Number
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Statement of Health for:
Child's Name
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Is there any information we should have regarding the welfare of this attendee; handicaps, restrictions, diets, etc?
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Yes
No
If yes, please provide:
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Is there any activity you do not with him/her to participate in?
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Yes
No
If yes, please provide:
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Check if child has ever had the following:
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Measles
Polio
Mumps
Chicken Pox
Whooping Cough
None of the above
List anything your child is allergic to:
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List information concerning medications to be given while away from home:
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Is your child covered by insurance?
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Yes
No
If yes, Insurance Company and Policy #
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Medical Consent
: I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered camper at Camp Jr, I hereby authorize any director, staff member, nurse, dean, lifeguard, or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the United States, when such medical or surgical treatment is necessary. I further understand that my personal health insurance will be the primary policy coverage in the case of accident or illness. Furthermore, if no personal health insurance policy information is provided by myself, I will be personally responsible for any medical charges incurred. I also give permission for my child to receive over-the-counter medication from the camp first aid station if necessary.
Required to proceed
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I agree
Discipline/Property Consent:
I understand that Northridge will make rules and guidelines that my child will abide by while attending camp. I understand that if my child misbehaves and does not respond in a positive manner, I may be called to pick him/her up. Warnings will be given, but if inappropriate behavior continues, I will come and get him/her and no refund will be issued. In addition, I will pay for any damage that is done to the camp and/or to personal property belonging to another individual. I give permission to the camp director and/or assistant camp director to inspect the contents of any or all of my child’s personal belongings, and to withhold and/or dispose of any improper or illegal contents.
Required to Proceed:
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I Agree
Activity Consent
: I give my permission for my child to participate in all camp-related activities. I understand by signing this release form, I am assuming such risks that are both known and unknown to me at the time.
Required to proceed:
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I agree
Promotional Consent
: I consent to the use of any videotape, photographs, audiotapes, or any other visual or audio reproduction in which my child may appear by EDEG or Northridge. I release Northridge and/or EDGE from any liability connected with the use of picture or voice recording as part of any promotion, recruitment, or fund-raising program.
Required to Proceed
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I Agree
I (parent or guardian of student) agree to be present for dropping off my child at camp on AUGUST 3rd, 8AM, at PASTOR GARY'S HOME.
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I agree
I am unable to drop-off my child in person
If you are unable to drop-off your child in person for camp, please contact Pastor Gary at
gsmith@thenorthridgechurch.org
.
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