Camper Paperwork | Bingle Camp

PLEASE NOTE: Your registration is not complete unless you pay your deposit. If you have not already done so, please click here to pay your deposit

Camper's Name*

First Name	Last Name

Which camp(s) is the child attending?*

Discovery Camp (Grades 3-5) June 2-7
Splash Camp (Grades 3-5) June 9-14
Music,Arts,Drama,Dance (Grades 7-12) June 16-21
Outdoor Skills Camp (Grades 6-9) June 23-28
Mini Camp(Grades 1-3) June 30 -July 2
H2O Adventure (Grades 6-8) July 7-12
Night Owl Camp (High School) July 14-19
Adventure Camp (Grades 3-5) July 21-26
Family Camp July 26 - 28

For Family Camp how many will be in your family group

Biological Gender*

Age as of June 1*

Grade Entering in the Fall*

If an adult is attending with a Mini Camp student, please list their name and relationship.

Parents Name*

First Last

Email*

Street Address*

City, State & Zip Code*

Primary Phone*

Work Phone

Other Phone

Is there another emergency contact you would like to list? If so, please do it here...

Local Church Affiliation (if applicable)

You can select up to 2 "cabin buddies" and we will do everything we can to make sure that they are all housed together, but we cannot make any guarantees.

First Name	Last Name

How did you hear about Bingle Camp?

This is the student's.....*

The following is the Health Form portion of the registration. This information will be printed and you will have the opportunity to fill in any changes on the first day of camp.

Medical Insurance Carrier

Policy Number

Insurance ID # or other Policy ID number

Does the student have any of the following (check all that apply)

Are their any other illnesses or allergies that we should know about?

If the student has ADD, Autism, behavioral, emotional, or mental issues, please describe the methods and medications used to manage these symptoms.

Date of last Physical

Date of last Tetanus Shot

Physician's Name

Physician's Phone

Physician's Street Address

Physician's City, State, & Zip Code

Do you give permission for the camp staff to provide acetaminophen (Tylenol), ibuprofen (Advil), hydro cortisone cream, diphenhydramine (Benadryl cream)?*

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by camp personnel to secure and administer treatment, including hospitalization, for the person named above. I hereby give permission to release any records necessary for insurance purposes and to provide or arrange necessary related transportation for my child. This completed form may be photocopied for trips outside of camp.

Parent/Guardian Initials - use your mouse or finger*

Print Parent/Guardian's Name*

Other Information We Should Know