Camper Application - Please fill out application in ink and return to your church.  You can request that an application be e-mail to you by requesting by clicking the link below "Request an Application". See MORE INFO on what all campers can and cannot bring to camp.

                                                                                                                     

 

 

 

 

                     

Name ___________________________________________ Age ____  Birthday _______________

            Last                      First                  Middle

 

Year in school _______     ( ) Male    ( ) Female   E-mail ___________________________________

 

Address __________________________________ City _________________________ State ____

 

Home Phone    ____________________________  Cell phone ______________________________

 

Medical Insurance _________________________________________ Policy #_________________

 

Father’s Name ___________________________ Phone _____________ Work # _______________

 

Mother’s Name ___________________________ Phone _____________ Work # ______________

 

Emergency Contact _______________________ Phone ______________ Work # ______________

 

Physician ________________________________________ Phone # ________________________

 

Dentist __________________________________________ Phone # ________________________

 

Church Name _____________________________________________________________________

 

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

MEDICAL HISTORY

 

If necessary, describe in detail the nature and severity of any physical and /or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof.  Submit this notification in writing and attach it to this form.  Include names of medications and dosages that must be taken.

 

Check the following areas of concern for this student.  If necessary, add another page with details.

 

1.  For your child’s safety, and our knowledge, is your student a:

 ____ good swimmer     ____ fair swimmer    ____ non-swimmer

 

2.  Does your child have allergies to:

      ___ pollens   ____ medications   ____ food    ____ insect bites

 

3.  Does your child suffer from, or has ever experienced, or is being treated currently for any of the  

     following:

      ____ asthma   ____ epilepsy/seizure disorder   ____ heart trouble   ____ diabetes

      ____ frequently upset stomach   ____ physical handicap

 

4.  Date of shots:  Diphtheria/Pertussis/Tetanus (DPT) _____   (MMR) ______   (Polio) ______

 

5.  Is your child allowed to take Tylenol?  Yes or  No   If not what can they be given?   ___________

 

6.  Does your child wear:   ____ glasses    ____ contact lenses

 

7.  Should your child be restricted for any reason?  Please explain.

 

For your information, we expect each student to conform to these rules of conduct.

          No possession or use of alcohol, drugs, or tobacco

          No student can drive

          No fighting, weapons, fireworks, lighters, or explosives

          No offensive or immodest clothing

          No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters

          Participation with the group is expected

          Respect property

          Respect one another, staff, and adult leaders

          Respect and comply with event schedules

 

Students who fail to comply with these expectations may be sent home at their parents’ expense.

 

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities.  I agree to abide by the stated personal limitations and code of conduct.

 

Student signature ________________________________________ Date _____________

 

 

Activities may include, but are not limited to: cookouts, boating, various water activities, basketball, tetherball, volleyball, baseball, fishing hiking, biking, concerts, Bible studies, & hayrides.  Note:  If you desire to limit your child’s participation in any event, please submit your wishes to the camp director prior to that event. (Contact camp director if you have any questions.)

 

__________________________________________ has my permission to attend all youth activities

                       Name of Student

 

Sponsored by ________________________________________________________(hereinafter the

                                                      Name of Organization

“Camp” from ___________ to ________________.

                        Date                         Date

 

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Camp and its staff of any liability against personal losses of named child.

 

I/ We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Camp.  I/ We understand that there are inherent risks involved in any ministry or athletic event, and I/ We hereby release the Camp, its Pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/ our child’s involvement.  In the event that he/ she is injured and requires the attention of a doctor, I/ We consent to any reasonable medical treatment as deemed necessary by a licensed physician.  In the event treatment is required from a physician and/ or hospital personnel designated by the Camp, I/ We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.  I/ We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider.  Further, I/ We affirm that the health insurance information provided above is accurate at this date and will, to the best of my/ our knowledge, still be in force for the student named above.  I/ We also agree to bring my/ our child home at my/ our own expense should they become ill or if deemed necessary by the student ministries staff members.

 

 

Parent/ guardian signature _________________________________________ Date ____________

 

 

If you want to purchase a "Camp Hugh" shirt for this year you can do so for an additional cost.  Prices are listed below.  Money for the shirts are due by June 23rd.  You must check the box if you want a shirt and you must turn in your money.

 

T-Shirt

Yes _____  No _____

 

Sizes

Youth L  _____  Youth XL _____

Adult S _____  Adult M _____  Adult L  Adult XL _____

Adult XXL _____  Adult XXXL _____ 

 

Prices

All T-Shirts are $10.00