Camper's Name First Name Last Name Which camp(s) is the child attending? * Mini Camp (Grades 1-3) June 30 - July 2 Splash Camp I (Grades 4-6) June 16 - 21 Adventure Camp (Grades 6-8) June 23 - 28 Night Owl Camp (Grades 9-12) July 7 - 12 Camper's Birthdate * MM DD YYYY Camper's Sex * Male Female Grade Entering in the Fall * Parent/Guardian Name * First Name Last Name Second Parent/Guardian Name If applicable. First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent's Primary Phone * (###) ### #### Secondary Phone (###) ### #### Emergency Contact/Primary Contact Church Affiliation (if applicable) Cabin Buddy Requests 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. 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 Camp Photo Release I acknowledge that, by agreeing, Bingle Camp has permission to include photos of my child in promotional materials as specified. Full release may include publication on website, brochures, Facebook and Instagram. Photo Release Please select level of release I AGREE entirely to the Camp Photo Release. I DO NOT agree. Bingle Camp may not use photos of my child for any promotional materials. I Agree - Bingle Camp may use photos of my child for website and brochure only, no Facebook/Instagram I Agree - Bingle Camp may use photos of my child for brochures and print materials only, no photos online Camper Medical Information Medical Insurance Carrier Policy Number Insurance ID# or other Policy ID# Does your camper have any of the following? Check all that apply. Seasonal Allergies Headaches/Migraines Upset Stomach/IBS Bee sting allergies Fainting Sleepwalking Asthma Betwetting 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 MM DD YYYY Date of Last Tetanus Shot MM DD YYYY Physician's Name Physician's Phone (###) ### #### Physician's Office Name Physician's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Do you give permission for the camp staff to provide acetaminophen (Tylenol), ibuprofen (Advil), hydrocortisone cream, diphenhydramine (Benedryl cream) as needed? * Yes, I do give permission. No, I do not give permission. Is there anything else about your camper we should know? Parent/Guardian Acknowledgement * Please write your full name below in order to electronically sign acknowledging that the information provided in this form is accurate. After you submit this registration form, you will be redirected to a payment page. There is a $50 deposit fee for each registered camper due at the time of registration. Thank you!