WCBC Camper Application

Camper Information

Camper's Full Name(Required)

First Middle Last

Preferred Name, if desired.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Camper Phone

Gender

Male

Female

Date of Birth

Age

Last Grade Completed

Name of Home Congregation

Have you been baptized?

Yes

No

Parent Information

Parent Name(Required)

First Last

Cell Phone(Required)

Work Phone

Home Phone

Email(Required)

Medical

ALL Medication MUST be handed in to the nurse upon arrival to camp. Please provide us with a copy of your medical insurance card prior to leaving for camp. Your child will not be registered until we have payment and a copy of your insurance card.

Physician Name

Physican Phone

Are there any medical conditions that we should be aware of or that would prevent your child from participating in activities?

Please list any recent injuries, operations or serious illnesses.

Are there any medical, social, mental, or economic problems that the director should be made aware of?

This form will only be reviewed by the Director. Please explain as best you can.

Please list any recent injuries, operations or serious illnesses.

Please list medications and dosages that your child is currently taking.

Medication

Dosage

Please provide detailed instructions regarding any medications that your child is currently taking.

Is your child allowed to take over the counter medications?(Required)

Yes

No

If yes, can you please list any that you would prefer your camper NOT to take.

Please list any allergic reactions to medications that your child has or has preciously had.

Please list any food allergies that your child has.

Please list any other allergies that your child has.

Such as bee stings, poison ivy. or other misc items.

Does your child sleepwalk or have nightmares?(Required)

Yes

No

If yes to sleepwalking or nightmares, please explain.

Camper Information

Parent Information

Camp Information

Medical

Contact Program Staff