Champion's Camp Camper Registration Camper's Name* First Last Date of Birth* MM slash DD slash YYYY Camper's Age at time of camp (September 9)*Camper's Gender*T-Shirt Size*Youth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAdult XXLAdult 3XLAddress* Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Parent/Guardian InformationParent/Guardian Contact Name*Parent/Guardian Phone #*Church/Group InformationIs the camper attending with their church or group home?* Yes No Church/Group Home Name*Church/Group Home city*Emergency ContactEmergency Contact Name*Relationship to the Camper*Emergency Contact Phone #*InsuranceInsurance CompanyName on Insurance PolicyInsurance Company Phone #Policy NumberMailing Address for Medical Claims (see back of insurance card)Does your Insurance Company require notification prior to emergency health care at a hospital?* Yes No If yes, Phone Number*Will a parent, family member, or caregiver of the camper be attending the camp?* Yes No If yes, name of parent/family member/caregiver*Who will be coming as your buddy to Champion's Camp? Type none if you want a buddy assigned to you.*Main Language or Way to Communicate*Camper Health History and Disability InformationDiseases/AllergiesChronic or recurring illness (please explain)Recent Operation or Serious Injuries (include explanation and date)Special Diet (please explain)Can camper climb stairs* Yes No Can camper sleep in top bunk?* Yes No Permission is given for my camper to receive over the counter medication from camp leaders or staff.* Yes No Degree of Disability* High: Requires constant assistance Moderate: Performs at slow speed/ with assistance Mild: Self-care with minimal or no assistance Please describe the camper's disability/ diagnosis:*Describe any challenges with movement, eye-sight ,hearing, or thinking:*Special Safety Needs/Crisis Plan:*Does the Camper experience seizures and if so how often?* Yes No How often do seizures occur?*Does the camper use any special equipment?* Yes No Please Describe Below:*Camper needs assistance on the following daily tasks. Please check all that apply* Select All Dressing Showering Deodorant Shaving Brushing Teeth Using the Toilet Washing Hair Menstrual Hygiene Brushing Hair Incontinence Supplies None Other:I consent to my child participating in the following camp activities. Please check all that apply.* Hiking Swimming Pedal Boating Climbing Running Water Games Should the camper be restricted from any certain activities?* Yes No If yes, describe:*Is this the campers first time to attend camp?* Yes No Extra space for any additional camper information:LodgingBase price for camp ($100) includes lodging in cabins in bunk beds. Lee Lodge hotel rooms are an additional $15 per person.Do you prefer a private accommodation with your buddy in Lee Lodge hotel room?* Yes No This may be needed for wheelchair purposes (although some cabins have accommodations). Cabins are housed same gender. Mother/son, father/daughter, or mixed gender buddy and campers may need to be housed in a hotel room.Health History and Treatment AuthorizationConsent* By checking, you agree to the below authorization form.The health history provided above is correct to the best of my knowledge and belief, and _____________________________________ (the person herein described) has permission to engage in all prescribed activities, except as noted. In the event of an emergency, I hereby authorize the physician selected by the Champion’s Camp Director to consent to hospitalization, secure proper treatment for, and to consent to injection, anesthesia or surgery which is deemed advisable by and to be rendered under the general or special care of any physician or surgeon (after reasonable attempts to reach me are made). I authorize the release of medical information to the health plan indicated for information requested by the health plan to determine the payment of medical benefits. Photography Release: I understand that promotional photographs or videos may be taken during the camp. Permission is granted for photography or video to be used by the LBC for promotional purposes only. A signature on this release is not required for camp attendance. We do this in order to respect the privacy of campers, buddies and their families. Name of Responsible Party or Legal Parent/Guardian* First Last Your typed name and checked box above will serve as an electronic signature for the authorization.Date* MM slash DD slash YYYY Deposit and PaymentWhat method will you pay for camp deposit today?* Pay by credit card with this form Mail a check to Tall Timbers Product Name* Price: One camper deposit-$50One camper deposit-$50 by check mailed to Tall TimbersCredit Card*Card Details Cardholder Name Δ
