Please enable JavaScript in your browser to complete this form.Camper Information - Step 1 of 4Camper Name *FirstLastCamp Program - Please choose carefully! *Farm Camp - OvernightFarm Camp - Daytime OnlyRanch Camp - OvernightRanch Camp - Daytime OnlyTeen Leadership WeekOvernight Campers stay on site from Sunday - Friday. Daytime Only campers will be picked up at 9pm daily and sleep at their own homes. Original Order Number (can be found in email) *Birth Date *Age at Camp *Sex Assigned at Birth *MaleFemaleGenderLegal Parent/Guardian #1 *FirstLastRelationship to Camper *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Home or Work PhoneLegal Parent/Guardian #2 *FirstLastRelationship to Camper *Address (if different than above)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Home or Work PhoneEmergency Contact #1 *FirstLastRelationship to Camper *Best Phone Number for Emergency Contact *Emergency Contact #2 *FirstLastRelationship to Camper *Best Phone Number for Emergency Contact *Proceed to Health HistoryHealth History *Frequent Ear InfectionsHeart Disease/DefectConvulsions/SeizuresDiabetesBleeding/Clotting Disorders HypertensionRespiratory ProblemsADD/ADHAAsthmaEating DisorderOtherNoneCheck all that apply. Please use field below to list approximate dates of any known conditions.Please list approximate dates and details of any conditions selected above.Diseases *Chicken PoxMeaslesGerman MeaslesMumpsOtherNoneCheck all that apply.Please list approximate dates and details of any diseases selected above. Allergies *Hay FeverIvy PoisoningInsect StingsPeanutsTreenutsShellfishDairyEggsOtherNonePlease list any additional allergies. Please provide an explanation of any conditions, diseases or allergies noted above. (On going treatments, medical, management strategies)Please describe any current health conditions requiring medication, treatment, restrictions, or considerations at camp:For each medication, list name of medicine, dosage, when taken, and purpose of medication. Please note that all medications must come to camp in an original pharmacy container with the camper's name on the label. Does this camper have any physiological, behavioral, physical disability, or learning disability conditions which could affect the experience of the person at camp? If yes, please explain:Does you camper have any dietary restrictions we should be aware of? Name of Primary Care Physician *COVID19Has your camper ever tested positive for COVID19? *YesNoIf yes, approximate date of positive test:Has your camper been fully vaccinated against COVID19? *YesNoHas your camper received a COVID19 vaccine booster? *YesNoProceed to Insurance Information Is the camper covered by family medical/hospital insurance? *YesNoIf yes, indicate medical/hospital carrier:Policy NumberName of InsuredRelationship to camper:Please upload a photo of insurance card: Click or drag a file to this area to upload. Your family's medical insurance is expected to provide primary coverage for illness and accidents, with The Center's insurance providing additional accident coverage (such as your deductible amount and expenses beyond the scope of your coverage). The Camp will make every effort to contact you in the event that your child needs medical attention, so that you may choose to take your child to your own doctor or treatment facility. If your child's condition necessitates our obtaining medical treatment for them, we will do so, as we continue our efforts to contact you. Emergency AuthorizationIn the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, order appropriate diagnostic testing, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper named above. Signature of parent or legal guardian *Clear SignatureName:Parents will be notified of illness or injury to campers in the following cases: temperatures over 100.3 degrees, injury or illness needing the care of a physician, any other unusual illness, injury or behavior that the camp director believes the parent would want to know or for which the parent has specifically requested notification. This health history is correct so far as I know and the above named camper has my permission to engage in all activities except as noted. I hereby give my permission to The Center to 1) provide ongoing health care including MOTRIN, TYLENOL, ANTIBIOTIC OINTMENT, HYDROCORTISONE, ORAL & CREAM BENADRYL, INSECT REPELLENTS CONTAINING DEET and other medications as prescribed and 2) To select medical personnel and to arrange or provide necessary related transportation. Signature of parent or legal guardian *Clear SignatureProceedCamper Code of Conduct - Please print or 'save as' to read in entiretyParental Release & Camper Waiver - Please print or 'save as' to read in entirety My signature below, expresses my consent and agreement to the following: *Camper Code of Conduct: I have read and will review this with my camper and as a family we agree to uphold the values of campParental Release: I have read and agree to the parental releaseCamper Participant Waiver: I understand the risks associated with campSignature *Clear SignatureWebsiteProceed to Payment Share this:Click to share on Facebook (Opens in new window)Like this:Like Loading...