Wisconsin District Junior Camp 2018 Registration Form

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2 Wisconsin District Junior Camp 2018 Registration Form Monday, June 18 at 1:00 pm - Friday, June 22 at 2:00 pm Completed Forms and Fees Due April 30, 2018 (Add $15 late fee if postmarked after April 30th) Mail to: Wisconsin District Children's Ministries, PO Box 903, Marinette, WI Parent/Legal Guardian (print clearly) Address: City: State/Zip: Phone: Home Church: Pastor: I have read the camp rules and the camper(s) listed below have my permission to attend the Wisconsin District Junior Camp. I will be responsible for the cost that may result of willful destruction of camp property or the property of other campers. Parent/Legal Guardian's Signature: CAMPER FOUR CAMPER THREE CAMPER TWO CAMPER ONE The above named camper(s) is/are associated with our church, has read the camp # of Campers X $ = $ rules, and has my recommendation to attend the Wisconsin District UPC Junior Camp. # of DVD's X $5.00 = $ # of Pictures X $5.00 = $ Late Fee (after 4/30) $15.00 = $ Pastor's Signature: Date: Total Enclosed (credit/church check) = $

3 Wisconsin District Camp Health Screening Camper s Name: (If you have multiple campers, please copy health forms for each camper) Section 1: Camper First: Middle: Address: Date of Birth City, State, Zip: Home Phone: Home Church: City: Pastor: Pastor's Phone: Section 2: Parent or Guardian/Emergency Contact (if camper is under 18) First: Relationship: Address: City, State, Zip: Home Phone: Work Phone: Insurance Carrier: Insurance Carrier Phone: Policy #: Section 3: Health History (to be filled out by parent or guardian) Y=yes N=no Is camper subject to: Frequent Colds Sinus Trouble Seizures Allergies Sleep Walking Bed Wetting Fainting Asthma Treatment for any above conditions: Has camper had: Rheumatic Fever Scarlet Fever Head Lice, if so last occurrence? Chicken Pox Appendicitis Hernia Mumps Tuberculosis Heat Exhaustion Polio Breathing/Lung Disorder explain: Heart Trouble, if so, medication used: Sugar Diabetes, if so, is insulin used? yes no Insulin Type: Other Diabetes medication used: Does camper have allergic reaction to: Drugs, please list: Animals, please list: Food, please list: Stings, please list: List treatment for stings: Does camper carry a bee sting kit? yes no Location of kit: Page 1 of 3 Updated: 2009

4 Wisconsin District Camp Health Screening Camper s Name: Is camper currently taking any medications? yes no If yes, please list medications, dosage and reason for taking. Medications MUST be kept in the nurse's station if the camper is not with a parent and MUST be in original pharmacy bottle with label intact: (exception: asthma inhaler): (Please fill out a Meds-Allergies form if your child will be keeping medication with the nurse) Any recent exposure to communicable diseases? yes no If yes, please explain: Description of any physical condition requiring special attention: Any specific activities to be restricted? (explain) Does the camp nurse have permission to give camper: Tylenol: yes no Anti- histamine: yes no Aspirin yes no Ibuprofen: yes no Decongestant: yes no Please list any other conditions/situations that camp staff should know about the camper: Weight: Height: Date of last Tetanus shot: REQUIRED: Are immunizations current? yes no If no, please explain: This health history is correct so far as I know, and is up to date as of the last 90 days. The person herein described has pe rmission to engage in all prescribed camp activities except as noted. Emergency Authorization: I hereby give permission to the medical personnel selected by the camp officials to order x-rays, routine tests and treatment for me or my child, as in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for me or my child as named above. I hereby give permission to transport me or my child for medical assistance. I hereby give permission to the WI District UPCI Camps to use photos, likenesses, and images of me for marketing and publicity purposes. This form may be photocopied for use at camp. I understand that I am responsible for payment of all medical treatments received from non-camp sources. I also give permission for the camp medical staff to administer over-the-counter medications to my child, that the physician has approved on page 2 of this form. I also give permission for my child to participate in all camp activities. Parent/Legal Guardian Signature: REQUIRED: Relationship to camper: Section 4: Medical Screening - By Certified Medical Personnel: I have screened the above applicant and approve of his/her participation in the physical and out-ofdoors activities of the camp program. Please list any restrictions or concerns: Signature: Title: Phone: Date: Page 2 of 3 Updated: 2009

5 Wisconsin District Camp Health Screening Camper s Name: Please list all medications taken by your child, including time and dosage. Medications A.M. P.M. Please indicate if your child has any allergies, and what they are. Allergic to: Notes: Page 3 of 3 Updated: 2009

6 Camper Registration Guidelines Campers must submit a camper registration form with camper, parent, and pastor signatures; health form signed by a physician or registered nurse; fee of $175 per camper; if ordered, $5.00 per drama DVD or picture packet (includes dorm, team, and class). Submit these through your church contact person/office. Registration forms received after April 30, 2018 will be charged an additional $15 late fee. Space is limited with no guarantee that late registrations will be accepted. Please note that we only accept church checks and church or personal credit cards. Send camper forms/ fees to: WI District Children s Ministries, P.O. Box 903, Marinette, WI The State of Wisconsin Health Department requires that each child be checked for head lice before lodging accommodations can be assigned. It is suggested that a qualified person check your child for head lice prior to camp; however, camp staff must perform a lice check when campers arrive. *************************************** Unsigned health forms will be screened by the camp nurse at a cost of $30. Health forms may be brought on day of arrival. During camper registration, all medications must be checked in to the nurse s station. Medications must arrive at camp in their original container with the camper s name, doctor s name, and pharmacy information on it. *************************************** Campers are pre-assigned to a dorm and directly accountable to two assigned counselors. (If you have a special rooming request, please list it on the registration form and we will do our best to accommodate.) Counselors will assist with any personal needs. Campers are also accountable to any other camp staff directing activities and are expected to attend all scheduled activities. If a child needs to be excused from a recreational activity due to a health concern, a note from the parent/legal guardian is required. Campers may not change assigned dorms, classes, or teams without permission from the camp registrar. Campers need to bring: Soap, toothbrush/paste, towels/washcloths, warm bedding/pillow Clothing for daytime activities, evening worship service, and sleeping Warm sweater or jacket Mosquito repellant and/or sunscreen Please label all belongings with the child s name. The camp fee provides three meals per day. If desired, a camper may bring spending money for soda machines and the concession stand. Please read the attached dress code and prohibited items. By signing the camp applications, campers and staff agree to follow these guidelines. Wisconsin District Junior Camp Dress Code & Guidelines 1. Junior Camp is a closed campus; no visitors are allowed. Pastors and spouses may visit, but must register at office. 2. If unauthorized items are brought, security will confiscate the item with no guarantee of a safe return. Items not allowed: knives (including pocketknives), slingshots, water guns, or any kind of weapon (real or imitation); unauthorized walkie-talkies; heaters, or air conditioners (due to the power supply required); CD players, IPod, MP3 s, computers, tablets, musical instruments, electronics, handheld games, are prohibited. 3. Cell phone and electronics policy: No one under 18 may use their cell phones (calling or texting) during Junior Camp. Adults, age 18 and older, may use their cell phones for calls or texting when they are not with campers. Absolutely no digital pictures of campers may be taken in dorms or bathrooms and no pictures may be posted to any internet site. The Wisconsin District Children s Ministries will take official pictures for the picture packets, our files, and for promotional use. Please understand this policy is to protect the minors in our care. 4. Please follow the dress code below. It will be adhered to even if it differs from your personal opinion. Security will ask you to change if clothing violates it. *************************************** Dress Code for Girls and Ladies Daytime/ Evening Service: Skirts and shirts or dresses with hemlines below the knee must be worn at all times. Recreation: Culottes which look like a skirt may be worn. These must have a skirt panel and hemline below the knee. Sleepwear: Full length, modest bathrobes must be worn when visiting the restroom. Not permitted: Sleeveless outfits (unless worn under a sweater or jacket) Shorts, slacks, make-up, and jewelry Clothes with unacceptable slogans, symbols, or pictures on bust line or buttocks areas Skirts/dresses with slits above the knee; tight skirts or dresses Tight or too short t-shirts, cap sleeve t-shirts, or immodest necklines Water Fight Dress Code: Camp sports shirt or dark colored, loose fitting shirt and nonclinging, dark colored skirt, culottes, or jumper. Dress Code for Boys and Men Daytime/ Evening Service: Pants and shirt must be worn at all times. All shirts must have sleeves. All pants must be full-length. Hair must be cut so that it is off the collar and ears. Recreation: Full-length modest recreation pants such as jeans, sweat, or athletic pants Sleepwear: Full length, modest bathrobes or sweat suits must be worn to the restroom. Not permitted: Sleeveless shirts (only T-shirts worn under a shirt) Shorts of any length Make-up and jewelry Clothes with unacceptable slogans, symbols, or pictures on chest or buttocks areas Tight or immodest pants; Tight or too short t-shirts and muscle shirts Water Fight Dress Code: Camp sports shirt or dark colored, loose fitting shirt and nonclinging, dark colored pants.

7 Wisconsin District Junior Camp Credit Card Form (OPTIONAL) To pay by credit card for camper or staff fees, please fill out all information and send with registration forms to: Wisconsin District Children's Ministries PO Box 903 Marinette WI I agree to pay the following fees. Please charge my credit card. # of camper fees: X $175 = $ # of DVD s ordered: X $5 = $ # of Picture ordered: X $5 = $ Late Fees (if applicable) X $15 = $ Health Fees (if applicable) X $30 = $ # of teen staff fees: X $30 = $ # of staff shirts ordered: X $15 = $ Total to charge: $ Card Type ( ) Mastercard ( ) Visa Credit Card # 3-Digit CVV Expiration Date: Month / Year Name On Card (PRINTED) Billing Street Address (No PO Box's): City: State Zip: Cardholders Signature: