Welcome Campers!
Camp Sunshine Camper Registration
Please have the following information ready before you begin:
Insurance information, Emergency contact numbers, and Health information.
start
 
What is the Campers first & last name? *

 
What is the first & last name of the Custodial Parent/Guardian? *

 
Custodial Parent/Guardian's Phone Number? (xxx) xxx-xxxx *

 
What is the Campers full address? *

Street / City / State / Zip Code
 
What is the Campers date of birth?   (month/day/year) *

 
What is the camper's age? *

 
Identity of camper: Please pick the following that best describes your camper. *


 
What is the Campers gender? *


 
What is the Campers height *

 
What is the Campers weight? *

 
What size of shirt does the Camper wear? *

All sizes being assumed adult.

 
If you are not available in an emergency notify:

 
Emergency Contact #1 *

Please state Name // Phone // Relationship
 
Emergency Contact #2 *

Please state Name // Phone // Relationship
 
Camper Health History and Information

Mark all that applies to the Camper below:

 
Please list any additional comments about the Camper's health *

 
Date of last tetanus shot? (Month / Day / Year) *

 
May Tylenol or Ibuprofen be given if needed? *

     
 
If yes, Tylenol or Ibuprofen may be given if needed please specify dosage

 
Does the Camper have a special diet? *

     
 
If the Camper has a special diet, please explain

 
Any recent operations or serious injuries? (Include dates) *

 
Does the Camper have any chronic or recurring illness? *

 
Does the Camper have any specific activities to be restricted? *

 
To expedite registration upon arrival at camp, please have your child’s medicine labeled. Please put in ziplock bag and print name and age clearly and the exact times medicine should be administered. *

Does camper take any medication? If yes, please list
 
Female Campers

Has the Camper started menstruation?
     
 
Female Campers

If she has not started menstruation , has she been told about menstruation?
     
 
IMPORTANT:  Please notify the camp if the Camper has been exposed to any communicable diseases during the three weeks prior to camp so we are kept informed.

 
Any additional information that we need to know about your child? *

 
Special Considerations for Cabin Assignment? *

 
Each Camper is required to have current health insurance provided by the parent. The policy number and information must be listed before a child will be allowed to check into camp.

 
What is the name of your health insurance company? *

 
What is the policy number of your health insurance? *

 
Subscriber's Name? *

 
Medicaid Number? *

 
Please list the name & phone number of the Camper's doctor *

 
As custodial parent/guardian, I designate all matters of discipline and emergencies to camp authorities and release the camp supervisors, the YMCA, and Sertoma Clubs of St. Joseph for liability for accidents. I understand that if a serious injury or illness develops, medical or hospital care will be given and I will be notified. However, it it is impossible to reach me, I give permission for emergency treatment, x­-rays, or surgery as recommended by the attending physician and camp staff(s). *


 
I understand my child may be photographed during camp, through activities and field trips. I give my permission to use these photos for advertising, TV, and social media exposure to promote the Sertoma Clubs of St. Joseph Summer Camp (Camp Sunshine). *


 
Payment and Camp Information

Camp fee: $175

$100 dollars down payment is due now to reserve spot at camp. $75 will be due by May 31, 2017.

Please Make Checks Payable to: The Sertoma Clubs

Checks may be mailed to:

Camp Sunshine
Attn: Beth Beadle, Camp Director
1601 W. Brittany Street
Olathe, KS 66061 
 
In addition to your payment, please attach a photocopy of your health insurance card.

 
AGREEMENT:  By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. *

Thanks for completing this typeform
Now create your own — it's free, easy & beautiful
Create a <strong>typeform</strong>
Powered by Typeform