Camper Registration Form (2023) Step 1 of 6 16% About the CamperStudent Name(Required) First Middle Last Gender(Required) Male Female Student Preferred Name(Required) Please provide the name the student typically goes by. Student Email(Required) Student Cell PhoneStudent T-shirt Size(Required)Adult SmallAdult MediumAdult LargeAdult X-LargeAdult 2X-LargeAdult 3X-LargeMailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthdate(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade for 2023-24 School Year(Required)7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeHome Church and City(Required) School(Required) Has your child ever been baptized?(Required) Yes No Ethnic Heritage Asian American Native American African American Caucasian Hispanic Other To help us know we are reaching all God's children, we request that you check below that which applies to the student: About the Parent(s)/Guardian(s)Parent/Guardian 1 Name(Required) First Last Parent/Guardian 2 Name First Last Parent/Guardian 1 Email(Required) Parent/Guardian 2 Email Parent/Guardian Work PhoneWhose Work Phone? Parent/Guardian Cell Phone(Required)Whose Cell Phone?(Required) May we add you to our camp text alerts? Yes No The Camper & CampHow did you hear about Camp Freedom?(Required) Has your camper attended a camp before?(Required) Yes No How many camps have they attended?Roommate Request Name Roommate Requests are NOT guaranteed.Does your child have permission to go hiking with other students?(Required) Yes No Does your child have permission to do the following (check all that apply)?(Required) Swimming Fishing Does your child have permission to be baptized or remember their baptism at camp?(Required) Yes No Will your child need transportation to camp?(Required) Yes No Arrive at Pfrimmer's Chapel parking lot (505 Pfrimmers Chapel Road NE, Corydon, IN 47112) at 11:00 a.m. on July 11, 2023.Will your child need transportation from camp?(Required) Yes No Return to Pfrimmer's Chapel parking lot (505 Pfrimmers Chapel Road NE, Corydon, IN 47112) at 11:00 a.m. on July 15, 2023.Who is authorized to pick up your child? Health RecordEmergency Contact(Required) First Last Emergency Contact Phone(Required)Family Health Insurance Company Contract #Plan Code Group #Insurance CardMax. file size: 512 MB.Please upload a picture of the insurance card, if possible.Do we have permission to administer Tylenol or Ibprophen?(Required) Yes No Is your child having symptoms for any of the following?(Required) Hay fever, asthma, wheezing Eczema or frequent skin rash Convulsions/seizures Heart trouble Frequent colds, sore throats, ear aches Trouble passing urine or bowel movements Shortness of breath Menstrual problems Dental problems None of the above Are there other health concerns we should be aware of? Operations or Injuries Allergies Including Food AllergiesEmotional or Behavioral Symptoms Communicable Disease Medications Needed/UsedKindFrequencyDosageTo be taken during camp? Add RemovePlease include psychiatric, ADD, and ADHD medications.Special Conditions to Watch For Examples: bed wetting, sleep walking, fainting, behavioral conditions, etc.Are the camper's immunizations up-to-date?(Required) Yes No Please itemize immunizations below.Most Recent Immunization DatePolioMumpsDiphtheriaTetanusPertussisMeaslesRubellaHep. BOther Add RemoveShould the camper's activity be restricted because of any physical condition or illness? Yes No Please explain the physical condition or illness that restricts camper's activity.(Required) If applicable, please list any health-related dietary restrictions. Authorization of Consent for Treatment of MinorConsent(Required) I agree to the consent for treatment of a minor.I, the undersigned, parent of the below listed child, a minor, do hereby authorize the Camp Freedom staff, as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgery diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such a diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, and or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.Camper Name(Required) First Last Parent/Guardian Name(Required) First Last Parent/Guardian Signature(Required)Date of Signature(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Release of Pfrimmer's Chapel Church Inc.Consent(Required) I agree to the following statement.I shall indemnify, hold free and harmless, assume all liability for, and defend the Camp Freedom Staff, Pfrimmers' Chapel Church Inc., O'Bannon Woods State Park, it's agents, servants, employees, officers, volunteers, and directors from any and discovery cost, court costs, and all other sums which Camp Freedom, Pfrimmers' Chapel Church Inc., or O'Bannon Woods State Park assertion of liability, or any claim or action founded thereon, arising or alleged to have arisen out of the below listed child's use of real or personal property belonging to Pfrimmers' Chapel Church Inc., it's agents, servants, employees, officers, volunteers, and directors, or by the omission by the below listed child. I also release media liability and give the same aforementioned individuals and entities permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital and printed media.Camper Name(Required) First Last Parent/Guardian Name(Required) First Last Parent/Guardian Signature(Required)Date of Signature(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 PaymentCamp Registration Price: Credit Card Processing Fee Price: REGISTRATION FEES ARE NON-REFUNDABLE IN THE EVENT YOU ARE UNABLE TO ATTEND.Coupon Total Credit CardCard Details Cardholder Name
