2016 CAMP REGISTRATION FORM Please mail this form together with payment of all camp fees to: Montlure Camp, PO Box 42705, Tucson, AZ

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1 2016 CAMP REGISTRATION FORM Please mail this form together with payment of all camp fees to: Montlure Camp, PO Box 42705, Tucson, AZ Camper Information Camper Mailing Address: (First Name) (Nickname) (Last Name) (Street Address) Camper address: (City) (State) (Zip Code) T-Shirt Size: Date of Birth: Gender: Male Female Grade in Fall 2016: (mm/dd/yyyy) Please select one: Parent Information Please select one: Mother Father Guardian Mother Father Guardian address: address: Church Affiliation (if applicable) and Cabin Mate Request Full Church Church Address: Cabin mate request (please indicate just one): Transportation Travel for campers is provided to and from camp by chauffeured bus, with adult chaperones providing supervision. The bus route begins in Tucson, will make a stop in Casa Grande, in metro Phoenix, and a final stop in Cordes Junction. All campers are strongly encouraged to ride the bus. If the bus locations are not near your area and you would be interested in carpooling with others, please select the bus location closest to you or Your own transportation if the camp is more convenient, AND initial the Interested in a carpool box or boxes. This gives permission for the registrar to share your interest with others from your area who also grant this permission. Pick Up Return Please indicate one pick up and one return location by marking the boxes with an x Tucson Bus stop is St. Mark s Presbyterian Church, 3809 E 3 rd St., Tucson Casa Grande Bus stop is at the gas station, Florence Blvd west of Exit 194 Phoenix Bus Stop is University Presbyterian Church, 139 E Alameda, Tempe Cordes Junction Bus stop is at the McDonald s off Exit 262 Your own transportation (Plan to arrive and depart between 1 and 2pm) Initial Initial Interested in a carpool? (Your initials in these boxes gives the registrar permission to share your name and phone/ with other from your area) Please check this box if you are willing to be a bus chaperone from Phoenix or Tucson. If checked, you will be contacted well in advance to discuss scheduling and duties. Page 1 of 7

2 Camp Requested & Camp Fees Grades listed are for the school grade the camper is entering in Fall Space at camp is limited so each camp is filled on a first-come, first-served basis. If your choice of camp is unavailable the Registrar will contact you promptly. Juniors camp is for 4 nights/5 days, Junior High and Senior High camps run for 5 nights/6 days. Please select one camp and one corresponding payment tier. Senior High Junior High 1 Junior High 2 Juniors (grades 10-12) (grades 6-7) (grades 8-9) (grades 4-5) June 6-11 (Mon Sat) June (Mon Sat) June (Mon Sat) June (Sun Thu) Tier 1 ($450) Tier 1 ($450) Tier 1 ($450) Tier 1 ($400) Tier 2 ($550) Tier 2 ($550) Tier 2 ($550) Tier 2 ($475) Tier 3 ($650) Tier 3 ($650) Tier 3 ($650) Tier 3 ($550) ***Early bird discount Subtract $25 if the registration is submitted prior to April 15 th.*** *****Late Fee Add $50 if the registration is submitted less than two weeks before camp starts.***** Total camp fees to be paid: Camp fees will be paid by family: church: other: If fees are being paid by your church, presbytery, or other scholarship sources, please provide full details here: Source name: Source name: Source name: Contact person: Contact person: Contact person: Phone number: Phone number: Phone number: address: address: address: If Paying by Credit Card: Total Amount to be Charged: Name of Card: Credit Card # (Visa/MC/Discover/AmEx): Expiration: CVV# (the 3 or 4 digit number on the back of the card): Billing Address (if different from above): Financial Assistance is available to enable campers to come to camp who may otherwise be unable to attend due to financial circumstances. Initially, please contact your Pastor as the Presbyteries and many churches may have funds designated to support such situations. If necessary, your Pastor can request financial consideration on behalf of the camper from the Montlure Board via the scholarship form located at montlure.org, which will be done in strict confidence. We ask that you kindly consider a donation in addition to the actual camp fees to provide additional support to our ministry. Thank you. Donation $ Your gift will be formally acknowledged and is tax-deductible as allowed by law. Agreements and Signatures Please carefully read the following statements, and initial each one to confirm: I will notify the camp if my child is exposed to any communicable disease (for example: strep throat or mononucleosis) during the three-week period prior to attending camp. I give permission for photographs including my child to be used in camp publicity. I understand cancellations less than two weeks before camp starts will result in forfeiture of all camp fees. For cancellations more than two weeks before camp, fees paid will be refunded less a $50 handling charge per registration. PARENTS/GUARDIANS: I hereby affirm that I am the parent/guardian of this camper with joint or sole custody, and I hereby certify that all the above information is accurate and complete. Parent/Guardian Signature: Date: Print Name of Parent/Guardian: Relationship: Parent Guardian CAMPER: I agree to follow the guidelines and policies of Montlure Presbyterian Camp, and will demonstrate Christian respect for the facilities, the staff, and my fellow campers. Camper Signature: Date: Page 2 of 7

3 2016 CAMP MEDICAL FORM Emergency Contact Relationship: Relationship: General Information Height: Weight: Blood Pressure: Date of Last Exam: Family Doctor: Family Dentist: Phone Number: Phone Number: Allergies and Dietary Restrictions (If yes, please provide two non-expired EpiPens; one for your child Does your child require an EpiPen? No Yes to carry with them and one to keep in the cabin) If yes, please provide details about your child s anaphylaxis, including the date and description of the reaction. Does your child have any allergies? No Yes If yes, please explain allergic reaction details, date, and description. Food Allergens Drug Allergens Environmental Allergens Does your child have any dietary restrictions? No Yes If yes, please explain. Montlure Camp cannot accommodate dietary preferences. Page 3 of 7

4 Medications and Treatments Will your child be taking any medications while at camp? No Yes Medicine must be brought to camp in its original packaging. Send this form with the prescription medications in the pharmacy containers with appropriate labels; other remedies must be in original containers. Please send enough medication to last and place them in a sealed plastic bag (such as Ziploc) with your child s name written on the bag. Medication Dose Times taken each day Please explain the reason for the medication and any notes on giving this medication to your child Schedule Page 4 of 7

5 Medications and Treatments (continued) May the following over-the-counter medications be given to your child while at camp? No Yes Acetaminophen (Tylenol) No Yes Insect Repellent No Yes Antacids No Yes Pepto-Bismol No Yes Antibiotic Cream No Yes Robitussin No Yes Antihistamines (Benadryl, Diphenhydramine) No Yes Robitussin DM No Yes ASA (Aspirin) No Yes Sting Swabs No Yes Calamine Lotion No Yes Sudafed No Yes Cortaid No Yes Sunburn Spray (Solarcaine) No Yes Dimetapp No Yes Sunscreen No Yes Ibuprofen (Advil) Is there anything the camp needs to be aware of when giving any of the approved over-the-counter medications to your child? No Yes If yes, please explain. Will your child require any treatments while at camp? No Yes If yes, please explain what treatment(s) must be given to your child, including frequency. Does your child regularly take any medications that will not be taken at camp? No Yes If yes, please explain what medications your child takes regularly and why they are taken. Immunizations Please list the date of your child s most recent vaccination or booster, if any, for the following: Vaccination Immunized? Date(s) TB No Yes Chicken Pox (Varicella) No Yes Diptheria, Pertussis, Tetanus, Polio No Yes Haemophilus Influenza B No Yes Hep A No Yes Hep B No Yes HPV No Yes IPV/OPV No Yes MMR No Yes PCV (Pneumococcal) No Yes Meningococcal Meningitis (MCV4) No Yes If your child has not been fully immunized, please explain. Has your child had a TB Mantoux Test? No Yes If yes, date: What was the result of your child s most recent TB Mantoux Test? Please explain your child s positive result on the TB Mantoux Test. Page 5 of 7

6 Health History Has your child experienced, or is currently experiencing, any of the following conditions? ADD/ADHD No Yes Heart Disease No Yes AIDS/ARC No Yes Hernia No Yes Asthma/Inhaler No Yes High Blood Pressure No Yes Athlete s Foot No Yes Homesickness No Yes Back Pain or Injury No Yes Irritable Bowel Syndrome No Yes Bedwetting No Yes Kidney Disease No Yes Behavioral Issues No Yes Lice No Yes Blackouts/Fainting No Yes Menstrual Difficulties No Yes Bleeding disorder No Yes Mental Health Issues No Yes Cancer No Yes Motion Sickness No Yes Chest pain No Yes Mouth Injuries No Yes Crohn s No Yes Neck Pain or Injury No Yes Colitis No Yes Nightmares/Terrors No Yes Concussion No Yes Pneumonia No Yes Constipation/Diarrhea No Yes Problems Breathing or Coughing No Yes Convulsions No Yes Respiratory Ailments No Yes Dental Braces, Caps, or Bridges No Yes Rheumatic Fever No Yes Depression No Yes Seizures No Yes Developmental Delays No Yes Sinus Infections No Yes Diabetes No Yes Skin Problems No Yes Down Syndrome No Yes Sleepwalking No Yes Ear Infections No Yes Sore Throats No Yes Eating Disorders No Yes Speech Problems No Yes Epilepsy No Yes Stomach Aches No Yes Excessive weight gain/loss No Yes Tonsillitis No Yes Fetal Alcohol Syndrome No Yes Ulcer No Yes Frequent Colds No Yes Urinary Tract Infection No Yes Hay Fever No Yes Uses eye glasses or contacts No Yes Headaches No Yes Visual Problems No Yes Hearing Problems No Yes Other No Yes Please fully explain any conditions your child is currently experiencing. Diseases Has your child had, or currently has, any of the following diseases? Chicken Pox (Varicella) No Yes Mono (past 1 year) No Yes Hepatitis A No Yes Mumps No Yes Hepatitis B No Yes Rheumatic Fever No Yes Hepatitis C No Yes Scarlet Fever No Yes Measles (German) No Yes Whooping Cough No Yes Measles (Red) No Yes Please fully explain any disease(s) your child currently has. Page 6 of 7

7 Related Medical Questions Had your child had any operations? No Yes Please explain the operation(s), including dates. It is important to note if prior operation(s) will affect your child s health while at camp. Has your child ever been hospitalized or had a serious injury? No Yes Please explain the reason(s) for hospitalization(s) or the serious injury(ies) and the dates they occurred. It is important to mention any signs of illness that camp staff should look out for. Has your child been exposed to any communicable diseases within the last 3 months? No Yes Please explain what disease(s) your child has been exposed to, and when the exposure occurred. Does your child have any restrictions on activity? No Yes Please explain what activities must be restricted and list any special accommodations that should be made. Will your child require any special assistance while at camp? No Yes Please explain what assistance will be required. Is there anything you would like to discuss with the camp medical staff? No Yes Please explain what you would like to discuss with the camp medical staff. Please list any other medical information the camp should have about your child. Do you have medical insurance? No Yes Full Name of Policy Holder: Policy Holder Phone Number: Employer Name (if insured through company): Insurance Company / Plan Insurance Company Phone Number: Health Insurance Policy Number: Insurance Group Name or Number: Health Insurance Authorization for Health Care I authorize Montlure s health care team to provide routine health care; I authorize the release of medical records in case of illness or accident. In case of any medical emergencies, I understand that every effort will be made to contact the emergency contacts identified on this form. In the event the emergency contacts cannot be reached, I hereby give permission to the physician selected by the camp administrator to hospitalize and secure proper treatment for my child, including administering anesthesia or surgery. Parent/Guardian Signature: Date: Print Name of Parent/Guardian: Relationship: Parent Guardian Page 7 of 7

This document must accompany the CAMPER MAIL-IN registration form

This document must accompany the CAMPER MAIL-IN registration form CAMP ARROWHEAD 2016 CAMPER HEALTH HISTORY MAIL-IN FORM Mail this form with CAMPER REGISTRATION to: Camp Arrowhead Attention: Nancy Lafontaine 35268 Homestead Way Lewes, DE 19958 Dates will attend camp: