Camper Information Week of Camp Attending * Checkbox * Male Female Name * First Last Address * Date of Birth * First Time Camper? Yes No Grade in Fall Cabin Mate Preference Camper Email * Camper Cell * Church Camper Attends Payment Information Checkbox * Deposit Paid Cash/Check Balance Due * Amount Church is to Pay * If scholarship is need, please call 724-825-5613 To apply. Parent Information Parent's Email Address * Parent's Name * First Last Parent's Cell * Terms & Conditions PLEASE COMPLETE REGISTRATION FORM & RETURN ASAP. A DEPOSIT OF $50 IS DUE WITH REGISTRATION FORM & FULL PAYMENT IS DUE AT CAMP REGISTRATION. IF CAMPER’S CHURCH IS PAYING PART OR ALL OF CAMP FEE, IT IS PARENT/GUARDIAN’S RESPONSIBILITY TO ENSURE PAYMENT IS MADE TO CAMP CARMEL. MAKE ALL CHECKS PAYABLE TO: CAMP CARMEL. PLEASE MAIL COMPLETED REGISTRATION FORMS & PAYMENT TO: CHRISTINE CARSON, 323 DARR ROAD, ROSTRAVER TWP, PA 15012 Waiver * Agree WITH THE UNDERSTANDING THE LEADERS OF CAMP CARMEL HAVE TAKEN EVERY RESPONSIBLE PRECAUTION IN PREPARING & PLANNING EVERY ACTIVITY TO ENSURE THE SAFETY OF THE ABOVE REGISTERED CAMPER, I HERBY RELEASE ALL THE LEADERS AND THE CAMP FROM LIABILITY DUE TO ANY ACCIDENT WHICH MAY OCCUR ON OR OFF CAMP CARMEL’S PROPERTY. IN CASE OF MEDICAL EMERGENCY, I HERBY GIVE MY PERMISSION TO THE PHYSICIAN, ELECTED BY CAMP CARMEL STAFF, TO AUTHORIZE PROPER TREATMENT FOR, ORDER INJECTIONS, ANESTHESIA, OR SURGERY FOR MY CHILD, AS NAMED HERE-IN. FURTHERMORE, THE INFORMATION ON THIS FORM IS BOTH TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. FURTHERMORE, CAMP CARMEL RESERVES THE RIGHT TO USE PICTURES & VIDEO TAKEN BY CAMP CARMEL STAFF IN PROMOTIONAL MATERIALS, THE CAMP CARMEL WEBSITE & ALL PLATFORMS OF SOCIAL MEDIA. Signature * First Last Camper Name Allergy Info * Camper has No Known allergies (NO Environmental or Food Allergies) Camper has the following allergies (check & indicate reaction, medication) Environment: (seasonal allergies, insect bites/stings, poison ivy, etc) Food Camper is not currently taking any medications (prescription or OTC) Camper is currently taking the following medication (please list name & dosage & condition treating below) Other Allergy & Medication Info Other Info Camp Staff Needs to Know Date of last tetanus shot: * Camper takes for pain: * Tylenol Ibuprofen Restrictions * Camper is in good physical condition, free from contagious diseases & capable of participating in all camp activities. Camper has some restrictions - please list: (ex: can’t swim/weak swimmer, can’t ride a bike) Details on Restrictions Health Insurance * Policy ID # * Physician Name and Number * Emergency Contact Info Name * First Last Relation * Cell * Name * First Last Relation * Cell: * laickdesign © 2022. All rights reserved.