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 (Grades 3-6) July 4-9
H2O Adventure Camp (Grades 6-8) July 11-16
Night Owl Camp (Grades 9-12) July 18-23
Mini Camp (Grades 1-3) July 25-27
Just You & Me Camp (Ages 4-10 with Adult) July 30-August 1

Biological Gender*

Campers Birthdate*

MM

DD

YYYY

Grade Entering in the Fall*

If an adult is attending with a Just You & Me Camp student, please list their name and relationship.

Parents Name*

First Last

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

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.