Summer Camp 2012 Registration Form

NOTE: If you are registering for TEEN ADVENTURE WEEK, you will also need to download and print & sign this rafting permission form from Quest Expeditions. (It is a separate form)

After completing this Summer Registration Form you will be directed to a payment page.  If you do not at least submit the deposit today, your registration will be voided.

Week of Summer Camp for which you wish to register: *

This camper is a boy or girl: * please selectCamper is a BoyCamper is a Girl

Students Last Name: *

Students First Name: *

Students Date of Birth: *

Age by June 1st *

Students mailing address: *

Students City: *

State: AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI

Zip Code: *

Valid E-mail Address where parent can be reached: *

Emergency Contact #1 *

Emergency Contact #2

School student attends:

Does this camper attend Released Time Bible Classes at a DeKalb County School? * please selectYES this camper attends Released Time Bible ClassesNo

If your child attends a DeKalb County school in Alabama are you aware that if they participate in our Released Time Bible Classes all year they have opportunities to earn points that can lead to scholarships towards a week of summer camp at PBC? please read and selectYes I was awareNo I was not aware

Is this child enrolled in The Mailbox Club Lessons offered through Ponderosa?

Name of Church (if attending):

Has this camper ever attended a weekend retreat or summer camp at PBC before?

Roommate Preference (friend attending same week): Only 1 roommate request can be guaranteed and that friend must also request you as their roommate choice.

Health Information of student:

Please list any health problems, allergies, or special needs of this student:

Please list any activities that should be restricted while at camp:

Please check any that apply to this student: ADD/ADHD Asthma Depression Diabetes or Low Blood Sugar Ear Issues Eating Disorder Heart Hepatitis HIV Positive Seizures Other

I have checked my student for Head Lice and I understand that during check-in my student will be checked again for Head Lice. I understand that my child will NOT be allowed to stay at camp if any lice or eggs (dead or alive) are found on this student: * please read and selectYes

Date of last Tetanus or DPT shot:

Date of last doctor exam:

Family Doctor/Pediatrician: *

Doctors Phone number: *

Name of Campers Insurance Coverage: *

Campers Insurance Policy #: *

Campers Insurance Group #: *

Campers weight: *

Campers height: *

This health history is correct as far as I know, and the person described has permission to engage in camp activities. I understand that neither the camp nor the camps insurance company will be responsible for medical treatment or liability for any pre-existing conditions my child had before arriving at camp. * please read and selectYes

I hereby give permission to the first aid personnel selected by the camp to provide standard first-aid care and administer over-the-counter medications if needed in the event I cannot be reached during an emergency. If I cannot be reached during an emergency I hereby give permission to the physician selected by the camp to order x-rays, routine tests, hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child named above. please read and selectYes

I hereby give my permission to use pictures or videos of my child taken during camp in any promotional material in which my child may appear. Please read and agreeYes

Full Name of Parent completing this form: *

For proper identification please give the last 4 digits of the social security number of the parent completing this form: *

Phone number where parent can be reached in case we have any questions about this registration: *

Please list any prescription medication this camper will be bringing to camp: (Please have these medications ready to give to the nurse during check-in):

Please indicate here the name of the friend you are bringing (who has never been here before) for the Bring-A-Friend credit. (Once your friend has sent in their registration form and their deposit, then your account will be given a $50 credit. Your friend must enter your name in the next box.)

I am a first time camper at Ponderosa Bible Camp and I was invited to camp by: (enter your friend's name here so they can earn the Bring-A-Friend discount)

* Required