2015 Sumer Camp Registration Form
Online registration available at www.campluther.org
Mail completed form to: 1050 Road 4, Schuyler NE, 68661
Questions? Call us at: 402-352-5655 Email: [email protected]
CAMPER INFORMATION
Camper Name:
Gender: M:
Address:
F:
City/State:
Zip Code:
Birth date:
Grade 2014-2015:
School Name and City/State:
Church Name and City/State:
FREE T-Shirt size: Youth sizes: 6-8 10-12
14-16 Adult sizes: S
M
L
XL
2X
3X
CAMP INFORMATION
Preferred Camp Name and Date:
Alternate Camp Name and Date:
Cabin Mate Requests:
First Choice:
Second Choice:
Housing Request:
Tree Houses
Gerwick
Shadrach/Meshach
The Barn
(We will try our hardest to accommodate all requests! Please circle at least two choices)
PARENT/GUARDIAN INFORMATION
Home Phone:
Email:
Father’s Name:
Cell/Work:
Mother’s Name:
Cell/Work:
PAYMENT WORKSHEET
Cost of Camp (See brochure) :
$
DISCOUNTS:
Early Bird: ($20 off if paid in full before April 14th)
Additional Child Discount ($10 off AFTER first child from same family)
Campership (Contact Camp Office for financial aid)
-$
-$
-$
TOTAL DISCOUNTS:
-$
PAYPAL OR CREDIT CARD PAYMENT: $5.00 FEE
$
TOTAL COST:
$
(Total cost or $50 Non-Refundable deposit due with this registration. Balance due one week before arrival.)
PAYMENT OPTIONS (Please check one)
Check:
Account Number:
PayPal:
Visa/Mastercard/Discover:
3 Digit Code:
Expiration Date:
OFFICE USE ONLY:
Date Received:
Amount Received:
(Fill out below)
Balance Due:
2015 HEALTH HISTORY & EMERGENCY FORM
Name:
Date and Camp/Event:
Emergency Contact:
Relationship:
Home Phone:
Cell/Work:
Secondary Contact:
Relationship:
Home Phone:
Cell/Work:
Name of Physician:
Phone:
Dentist/Orthodontist:
Phone:
Health Insurance Carrier (or attach card):
Address:
Policy #:
Phone:
Known Medical Conditions: (If camper is prone to headaches, injury, etc. please send appropriate medication with instruction)
Please list any current medications and why being taken:
(Must be in original container, these will be collected and distributed per instructions)
Are there any dietary restrictions we need to know about?
Up to date on immunizations? Yes:
__
No:_______
Date of last tetanus shot:
This health history is correct and accurate as far as I know, and the person described herein has permission to engage in all prescribed
camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order X-rays,
routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related
transportation for this person. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected
by the camp director to secure and administer treatment, including hospitalization, for the person named. I allow this person’s
picture/video to be taken for use in promotion and publicity efforts of Camp Luther of Nebraska, Inc. unless this statement is crossed
out.
Signature of parent or Guardian (or self if over 18)
Date