Camper Paperwork

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?*
- Base Camp (Grades 1-3) June 15-`17
- Splash Camp (Grades 3-5) June 17-22
- Extreme Skills Camp (Grades 6-9) June 24-29
- Night Glacier Camp (High School) July 8-13
- H2O Adventure (Grades 6-8) July 15-20
Gender*
Student's Shirt Size
Email*
Age as of June 1*
Grade Entering*
If an adult is attending with this student, please list their name and relationship.
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)
- 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 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

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

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.