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Camp Registration Form

Name:_____________________________________	Gender: M / F
Address:___________________________________	Date of Birth: ___ /___ /_________
__________________________________________	Phone: (_____) _____ - _________
City:______________________________________	State:____ZIP:__________
Church:____________________________________ (optional)	Email:________________________ (optional)

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

Emergency Contact Numbers: (optional)  Cell: (_____) _____ - _________ Work: (_____) _____ - _________ Other: (_____) _____ - _________

Medical Questionnaire:

Does your child have allergies to any medications?Yes / No If yes, please explain:______________________ _______________________________________ _______________________________________ Does your child have allergies to any food products? Yes / No If yes, please explain:______________________ _______________________________________ _______________________________________

Does your child have allergies to any environmental elements such as insect bites?Yes / No If yes, please explain:_______________________ ________________________________________ ________________________________________ Does your child have any special needs we should know of to accommodate their stay with us? Yes / No If yes, please explain:_______________________ ________________________________________ ________________________________________

If necessary, do we have permission to give your child: Motrin Yes / No Pepto-Bismol Yes / No Topical Benadryl Yes / No Tylenol Yes / No

Health Insurance Information: Name of policy holder:____________________________________ Policy number:__________________________________________ Company:______________________________________________ See http://pathoflifecamp.org/medical.php for complete information on Camp medical requirements

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. This form must be postmarked by May 30, 2012 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.

Signature: __________________________________

Date:___________________