CAMPER'S NAME

First Name

Last Name

ADDRESS

Address Line 1

Address Line 2

City

State

Zip

Daytime Phone Number

Night-time Phone Number optional

Email

Camper's Birthdate

Camper's Age

Accepts only numbers

Grade Entering Into

Gender

                            FemaleMale                        

T-shirt Size

                            Youth SYouth MYouth LAdult SAdult MAdult LAdult XLAdult XXL                        This is the size that will be ordered for this camper

Cabin buddy / Counselor Request (request cannot be guaranteed) optional

Do you have a friend or counselor that you want to share a cabin with?

Your Church Name

YOUR CHURCH ADDRESS

Address Line 1

Address Line 2

City

State

Zip

Your Church Phone Number

Register Me For

                            Elementery Camper - $365    (Ages 5-10)Middle School Camper - $365    (Ages 11-14)Cadet Counselor - $175    (Counselor in training - Age 15+) (Counselor application also required)                        

** SAVE $20 ON TUITION WITH REGISTRATION SUBMISSION BY MAY 31ST.

Campers / Cadets: Please also complete the medical release form below in its entirety. Some questions are repeated from the registration form so our nurses have a complete record. Thank you for taking the time to complete the process.

MEDICAL RELEASE FORM:

CAMPER NAME

First Name

Last Name

Camper Birthdate

Camper Age

Accepts only numbers

Camper Gender

                            FemaleMale                        

Camper Height

Accepts only numbers

Camper Weight

Accepts only numbers

PARENT / GUARDIAN NAME

First Name

Last Name

PARENT / GUARDIAN ADDRESS

Address Line 1

Address Line 2

City

State

Zip

Parent / Guardian Daytime Phone Number

Parent / Guardian Night-time Phone Number optional

Parent / Guardian Email

EMERGENCY ALTERNATE CONTACT NAME

First Name

Last Name

Emergency Alternate Daytime Phone Number

Emergency Alternate Night-time Phone NUmber optional

FAMILY DOCTOR NAME

First Name

Last Name

Doctor Phone Number

Medical Insurance Company

Medical Insurance Policy Number

Last Physical Exam

              Choose the best option              Within 1 YearWithin 2 YearsWithin 3 YearsLonger Thank 3 Years                        

General Health

              Choose one              ExcellentAverageBelow Average                        

Date of Last Tetanus Shot

(Must be within 10 years. If not within 5 years, DT will be required if laceration or puncture wound occurs.)

Do you agree to the use of over-the-counter medicine for your child if needed?

YES

NO

Easily Sunburned?

YES

NO

Prescription Medicine Required?

YES

NO

Camper Allergies?

YES

NO

(Food / Medications / Insects / Etc...)Special Diet?

YES

NO

Chronic Medical Conditions?

YES

NO

(Asthma / Diabetes / Seizure / Etc...)

By choosing YES - I AGREE below, I affirm that I am a parent or legal guardian of the camper listed above, that the information provided herein is accurate, and that Lakewood Retreat has my permission to act in the best interest of my child's health if I cannot be contacted in a timely fashion.

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YES - I AGREE

NO - I DO NOT AGREE

When the form is fully completed, click the SUBMIT button below. If you do not see a submission confirmation and the form returns to the beginning, there is a field entry error. Review the form for red notated errors, correct each, and SUBMIT again. Please contact our office if you have any questions or difficulties - 352-796-4097. Thank you for your application. We hope to see you at camp!!

Submit