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Camper Registration
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Camper Registration
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
*
Female
Male
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...
*
First Time at Bingle Camp
Second Time at Bingle Camp
Third Time at Bingle Camp
Fourth (or more!) Time at Bingle Camp
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)
Seasonal Allergies
Headaches/Migraines
Upset Stomach/IBS
Bee sting allergies
Fainting
Sleepwalking
Asthma
Bedwetting
Frequent colds
Convulsions/Epilepsy
ADD/ADHD
ASD
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)?
*
Yes, I do give permission
No, I do not give permission
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
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
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.