Camper Registration – Bingle Camp

PLEASE NOTE: Your registration is not complete, and will not save, unless you pay your deposit at the bottom of this form.

Camper's Name*

First Name	Last Name

Which camp(s) is the child attending?*

Splash Camp I (Grades 4-6) June 26-July 1
Splash Camp II (Grades 4-6) July 24-29
Adventure Camp (Grades 6-8) July 10-15
Night Owl Camp (Grades 9-12) July 17-22
Mini Camp (Grades 1-3) July 6-8
Family Camp (Ages 4-10 with Adult) July 2-4

Biological Gender*

Campers Birthdate*

MM

DD

YYYY

Grade Entering in the Fall*

If an adult is attending Family Camp, list their name and relationship to the camper.

Parents Name*

First Last

Parents Name*

First Last

Email*

Street Address*

City, State & Zip Code*

Primary Phone*

Work Phone

Other Phone

Emergency Contact / Primary Contact*

Local Church Affiliation (if applicable)

You can select up to 2 Cabin Buddies and we will do our best to make sure that they are housed together. We cannot make any guarantees.

First Name	Last Name

How did you hear about Bingle Camp?

This is the camper'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 camper has ADHD, Autism, behavioral, emotional, or mental health concerns, 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

How many camps are you registering for today? There will be a $50 deposit for each camp registered.*

Product Name

Deposit Total

$0.00

If you would like to pay any more towards your balance, you can do so here...

If you like to donate to our Scholarship Fund to help other students go to camp, please add that here. You will recieve a reciept for this donation.

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Total

$0.00

By clicking submit, you agree for Bingle Camp to charge your credit card the amount listed above. You will receive a receipt immediately. If you do not receive it within an hour, please check your spam folder. Make sure to add binglecamp.org to trusted URL list.