Camp Registration - Path of Life Camp

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2012 Camp Registration Form

Required Camper's Name:	MaleFemale
Camper's Birthdate:*	(MMDDYYYY)
Address:*
City:*
State:*
ZIP code:*
Phone:*	(2223334444)
Email:
Church:

Please select the weeks your child is planning to attend:*

June 24–30	Junior High Camp #1	Amazing Race
July 2–6	Day Camp #1	Christmas in July
July 8–14	Junior Camp	Circus Week
July 16–20	Day Camp #2	Fantastic Forest
July 22–28	Teen Camp	Teen Week
July 30 – August 3	Day Camp #3	Knights Week
August 5–11	Junior High Camp #2	Horse Week
August 13–17	Day Camp #4	Western Week

Medical Questionnaire:

Does your child have any allergies to medications?* If yes, please explain:	YesNo
Does your child have any allergies to food products?* If yes, please explain:	YesNo
Does your child have any allergies to environmental elements such as insect bites?* If yes, please explain:	YesNo
Does your child have any special needs we should know of to accommodate their stay with us?* If yes, please explain:	YesNo

If necessary, do we have your permission to give your child:*

•Motrin	YesNo
•Pepto-Bismol	YesNo
•Topical Benadryl	YesNo
•Tylenol	YesNo

Health Insurance:
Check this box if you would prefer to bring your child's insurance information to registration.

Name of health insurance policy holder:*
Insurance policy number:*
Company:*

Parent/guardian contact information
I can be reached at:

Cell:	(2223334444)
Work:
Other:

Medical Requirements: New York State law requires that we have information regarding
your child's immunizations. Please bring your child's immunization record when checking in
on the first day of camp. If you prefer, we will be happy to photocopy the record for you.

To receive the early registration discount and reserve your child's place:
The non-refundable resident camp registration fee of $40.00 must be received by the camp.
See here for mailing address. This form must be submitted by May 30, 2012 at 11:59pm to
receive the early registration discount.

In case of emergency: I understand every effort will be made to contact me. However,
if I can not be reached, I give permission for the physician selected by the camp director
to secure proper medical treatment for my child.

By submitting this registration: I give my permission for the camp to use my child's
photograph in camp promotional information.