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
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