Camp Anew

Camp Anew Registration

Camp Session:
Enter your Email Address:
Camper's Name: Sex:
Camper's Date of Birth: Camper's Phone:

Camper's Current Grade: Name of School: Tshirt Size:
Street: City:
Zip/Postal Code:
Parent/Guardian
Parent/Guardian Home Phone: Parent/Guardian Work Phone:
Parent/Guardian Cell Phone:
Emergency Contact: Relationship:
Emergency Contact Home Phone: Emergency Contact Work Phone:

Name of Loved One Who Died: Relationship:
Date of Death: Cause of Death:
Camper's Response to Loss:
Significant Grief Issues:
Medications: Current Infectious Disease:
Allergies or Medical Concerns: Behavioral Problems/Bed Wetting/Other:

IMMUNIZATIONS: Check if up-to-date:
Diphtheria
Hepatitis B
Whooping Cough
Mumps
Polio
Rubella
Measles
Tetanus
Date of Last Tetanus Booster:
Insurance Company: Policy Number: Family Doctor: Office Phone:
Authorize Pickup Family, Church, etc.: How did you hear about Camp Anew?

In electronically signing this document, I hereby certify that this information is accurate and give my Permission for the use of photographs and videos including my child to be used in camp publicity: for my child to be transported in camp owned vehicles to and from off campus activities; for the release of medical records in case of illness or injury; and for the camper name herein to engage in all camp activities, except as noted by me and/or attending physician.  I also give my permission to the physician selected by Grace Adventures to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for the camper name herin.  I also give my permission to the Grace Adventure Health Officer to give routine nonsurgical treatment.:

Electronic Signature of Parent/Guardian:
Anti-Spam Question: Is fire hot or cold?
Camp Anew Cost: $250. A $50 deposit is required. After registration is submitted, you will be redirected to instructions on payment options.
We need financial assistance. Please explain:
Send me a carbon copy of this registration.