CAMP VICTORIA REGISTRATION PACKET
INDEX
Page
1- Check List Page
2- Required Proof of Age Form
3- Parent /Guardian Information Form
4- Selection of Camp-Week Session Form
5- Waiver for Participation &/or Parent Form
6-7- Emergency Contact Information Form
8-9- Camper Health History Form
10- Medical Emergency Form
11-13- Confidential Camper Info.Form
14- Instruction & Information Page
JoAnn Brewer {Owner/Director} (304)429-2775
Melissa Ramey {Owner?Director}(304)638-3516
Camp Victoria
_______ Address
Huntington, WV 25704
Copyright 2011, All Rights Reserved
____________________________________________________________
Page 1
Registration Packet
To complete your “Day Camp Registration Packet”, please follow the instructions.
If you choose to mail the packet, use this checklist as a guide before you mail it out.
CHECK LIST:
Did you remember to include:
___ Registration Form & Signed?
___ Health History / Emergency Form & Signed?
___ Immunization Record Enclosed?
___ Confidential Camper Information Form & Signed?
___ Photo of Camper?
___ Payment?
___ Proof of camper’s age? {Required for first time Registrants Only}
___ Proof of residency? {Only one (1) form required}
___ Separate check for each program and each camper?
** T-Shirt Size? {Youth} S (6-8) M (10-12) L (14-16)
____________________________________________________________
Page 2
REQUIRED - PROOF OF AGE
Please include a copy of child’s Birth Certificate or
Other Legal Documentation verifying age.
** Proof of age is required for first time
registrants only.
Camper _______________________________
Date of Birth ___________________________
Address ______________________________
______________________________________
Grade last attended in Sept.______________
Has address changed since last registration? Yes - No (circle)
____________________________________________________________
Page 3
PARENT / GUARDIAN INFORMATION
MOTHER/GUARDIAN
NAME:___________________________________
If guardian, how are you related?______________
ADDRESS:________________________________
_________________________________________
HOME PHONE:____________________________
WORK PHONE:____________________________
CELL PHONE:_____________________________
EMAIL:___________________________________
FATHER/GUARDIAN
NAME:___________________________________
If Guardian, how are you related?______________
ADDRESS:________________________________
__________________________________________
HOME PHONE:____________________________
WORK PHONE:____________________________
CELL PHONE:_____________________________
EMAIL:___________________________________
______________________________________________________________
Page 4
Selection of Camp-Week Session
Please select your 1st & 2nd choices of preferred Camp-Week Sessions
you would like your child to attend.
1ST CHOICE___________________________________
2ND CHOICE___________________________________
NOTE: If first choice is full, camper will be registered in second choice (if available). If a second choice is indicated and it is full, you will be contacted to inquire what you would like to do. If you do not choose another preference, you will be contacted should either choice become available.
***Completion of this form does not guarantee placement in the program desired. Incomplete forms will be returned voiding your registration.
Make check payable to:
JoAnn Brewer {c/o Camp Victoria}
Amount enclosed $__________ Initial Deposit ($50.00)
Amount enclosed $__________ Remaining Balance ($150.00)
Total amount given $__________ for camper fees on (date)___/___/______.
Mail to: Mrs. JoAnn Brewer {c/o Camp Victoria}
528 W. 26th Street
Huntington, WV 25704
____________________________________________________________
Page 5
WAIVER FOR PARTICIPANT AND/OR PARENT
In consideration of your accepting my or my child’s entry, I hereby, for myself, my child, our heirs, executors, and administrators, waive and release any and all rights and claims for damages I or my child may have against Camp Victoria
and its representatives, officers, employees, agents, successors, and assigns for any and all injuries suffered by myself or my child on any activity sponsored by these groups. I do hereby grant and give these groups the right to use my or my child’s photograph or image with or without my or my child’s name both single and in conjunction with other persons or objects for any and all purposes including, but not limited to private or public presentations, advertising, publicity, and promotion relating thereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold Camp Victoria harmless of and from any and all liability of whatever nature which may arise out of result from such uses. For the consideration stated above, I further agree that in the event that my child repudiates or attempts to repudiate such release, I will personally indemnity and save harmless Camp Victoria ~ Girls Day Camp, its successors and assigns, for any and all loss and damage occasioned thereby.
Signature__________________________________________
Date__________________ (check one) ____Parent ___Guardian
____________________________________________________________
Page 6
EMERGENCY CONTACT INFORMATION
{THIS FORM MUST BE FILLED OUT IN ITS ENTIRETY}
Camp Victoria ~ Girls Day Camp
Camp-Session Week __________________
Site ______________________
Camper’s Name (last, first)____________________________________________
Camper’s Address __________________________________________________
Birth date ____/____/_____ Age ______
Mother/Guardian
Name_________________________________________
Address_______________________________________
Home Phone___________________________________
Work Phone____________________________________
Cell Phone_____________________________________
Father/Guardian
Name__________________________________________
Address________________________________________
Home Phone____________________________________
Work Phone_____________________________________
Cell Phone______________________________________
____________________________________________________________
Page 7
** MUST PROVIDE THREE EMERGENCY CONTACTS
TO BE NOTIFIED IF PARENTS /GUARDIANS ARE NOT AVAILABLE IN AN EMERGENCY
Emergency Contact 1
Name______________________________________
Address____________________________________
Home Phone________________________________
Work Phone_________________________________
Cell Phone__________________________________
Emergency Contact 2
Name______________________________________
Address_____________________________________
Home Phone_________________________________
Work Phone__________________________________
Cell Phone___________________________________
Emergency Contact 3
Name______________________________________
Address_____________________________________
Home Phone_________________________________
Work Phone__________________________________
Cell Phone___________________________________
** If Emergency Contact has to be notified, they must provide and show a legal photo ID upon arrival, for the safety of your child. Thank You
__________________________________________________
Page 8
CAMPER HEALTH HISTORY
IMMUNIZATION RECORD - Attach a copy of your child’s Immunization Record - * required
HEALTH HISTORY & ALLERGIES - If YES,
give date(s) & details:
Asthma? No - Yes,______________________________
Insect Bites? No - Yes,_________________________
Seizures? No - Yes,___________________________
Latex? No - Yes,______________________________
Diabetes? No - Yes,___________________________
Over the Counter Medication? No - Yes,___________
_________________________________________
Hay Fever? No - Yes,_________________________
Antibiotics? No - Yes,__________________________
**Is an INHALER required for any of the above or Food Allergies? Yes - No.
If so, What is the name: ___________________________________________
Is an EPI PEN required for this allergy? No - Yes
Please give details_______________________________
______________________________________________
Is this allergy mild or severe? ___MILD ___SEVERE
Give Details ________________________________________________________
__________________________________________________
Page 9
DOES CAMPER:
Wear contact lenses? YES NO
Wear dental appliance? YES NO
Has camper had any operations or serious illness? YES NO - If YES, explain:______________________________________________________________
Does camper have chronic or recurring illness? YES NO - If YES, explain: __________________________________________________________________________
Does camper have any medical, physical, behavioral condition(s) that we should be aware of? YES NO - If YES, explain: ________________________________________________________________________________________________________________________________________________________________
Does camper take any daily medication(s)? (prescription & non-prescription) YES NO. If YES, list medication & reason taking it:
Med._____________________________________ Reason____________________________________
Med._____________________________________ Reason____________________________________
Med._____________________________________ Reason____________________________________
Med._____________________________________ Reason____________________________________
(If there is not enough room,please attach a separate paper)
Doctor (s) ____________________________________________ Address______________________________________________
Phone #______________________________________________
Hospital Preference ___________________________________
___________________________________________________
Page 10
PERMISSION TO TREAT IN A MEDICAL EMERGENCY
In the instance of a medical emergency, I understand that the staff of Camp Victoria ~ Girls Day Camp will always attempt to contact the parent/guardian first. I hereby give permission to the Staff of Camp Victoria ~ Girls Day Camp to seek emergency medical treatment including ordering x-rays, routine tests, or to provide or arrange necessary related transportation for my child/ward. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician to secure and administer treatment, including hospitalization for my child/ward. If there is a change in the above information, I will promptly notify the Staff of Camp Victoria ~ Girls Day Camp.
I hereby give Camp Victoria ~ Girls Day Camp permission to provide emergency care, as necessary.
*This completed form may be photocopied for trips out of camp.
Signature of Parent/Guardian _________________________________________
Date ___/____/_____
__________________________________________________
Page 11
CONFIDENTIAL CAMPER INFORMATION
To provide the best possible camp experience for you and your child, please share with us some information to the questions below in regards to your child. Please answer the questions to the best of your ability.
If you would like to discuss this information, please do not hesitate to call the Day Camp Director, JoAnn Brewer at 304-429-1396.
Camp Victoria ~ Girls Day Camp strives to provide a positive environment for all participants involved.
Any child whose behavior may include: physical/ verbal tantrums, an inability to demonstrate basic self help skills such as independence in toileting, is unable to follow directions, and may wander away from their group or demonstrates any other behavior that would put themselves or others at risk, may not be appropriate for the program. For the general welfare of campers and staff, the camp director reserves the right to dismiss any camper whose conduct or influence is detrimental to the Camps best interest.
**Please give us a call and we would be happy to discuss this program further with you.
__________________________________________________
Page 12
**Please explain any limitations or restrictions in any activities and the reason why: ___None ______________________________________________________________________________________________________________________________________________________
Please indicate those services that your child utilizes at his/ her school:
___Speech and Language Assistance
___Instructional Aide
___None
___Special Education Class
___Other(please describe)______________________________
Are there any custody issues of which we should be aware of: Yes No
If Yes, please describe: __________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________
Page 13
Please check any of the below that may pertain to your child:
___None
___A.D.D.
___Diabetes
___Emotional Concerns
___A.D.H.D.
___Tourette’s Syndrome
___Developmental Disability
___Aspergers
___Epilepsy
___Behavioral Concerns
___Autism
___Other (explain below)
Are there other medical, physical, behavioral or mental health conditions that we should be aware of?
___No ___Yes If Yes, please explain __________________________________________________________________________________
_________________________________________
I hereby indicate that all information given in the Registration Information Packet is, to the best of my knowledge, correct.
Signature__________________________________________
Date___/____/_____
**Please fold the Confidential Information Sheet in half and seal with a piece of tape or staple. Write campers name and camp week on the back**
Copyright 2011, Camp Victoria ~ Girl's Day Camp, All Rights Reserved.
