Registration 2010 - Step 1 of 2

Before beginning, please...

  • Scroll down and scan through the form. Be sure you have all the required information on hand (including health and insurance information).
  • Please do not submit the form without entering information regarding the camper's last tetanus shot.
  • When entering phone numbers and calendar dates, please be mindful of the preferred format. Following the examples will save time for the registrar.

CAMPER INFORMATION

     
Camper's Name    
Address  
City  
State  
Zip Code  
Date of Birth  
   mm/dd/yyyy
 		  
Age as of 6/13/10  
Grade entering in Fall 2010  
Sex  
T-Shirt Size (Adult Male Sizes)  
Is Camper a CLC Member?  
If so, which congregation?  
If not, which congregation?  

 

PARENT INFORMATION

Mother's Name
Father's Name
Parents' Address (if different from above)
Home Phone 555-555-5555
Cell Phone 555-555-5555
Work Phone 555-555-5555
Email Addresses of parents
Where did you get the Camp Website Information?
How or from whom did you learn about camp?

 

INSURANCE INFORMATION

Insurance Provider  
Policy / Group Number  
Policy Holder's Name  
Policy Holder's Date of Birth mm/dd/yyyy
Insurance Expiration  
Family Doctor's Name  
Family Doctor's Number 555-555-5555

 

HEALTH HISTORY INFORMATION

Please check all that apply to the camper.

ADD / ADHD Digestive / Bowel Trouble
Allergies to Food Dizziness
Allergies to Insect Stings Ear Trouble
Allergies to Meds Epilepsy or Convulsions
Aspbergers Heart Trouble
Asthma Menstrual Difficulties
Bed Wetting Uses EPIPEN
Diabetes     
     
Medications  
Medication Dosage  
Reason for Medication  
Side Effects of Medication  
     
Last Tetanus Date mm/yyyy
Any activity limitations  
Special Diet Needs  
Emotional concerns/conditions  
Any Additional Concerns  

 

ADDITIONAL INFORMATION

Years of Swimming Lessons
Concerns About Water Activity