CAMPER INFORMATION

* First Name: *

Middle Name:

* Last Name: *

* Gender: *

* Birthdate: *

*Email: *
(This email address will
be used for important
camp communication.)

Day Phone: *

ext.

Evening Phone:

ext.

*Address Line 1: *

Address Line 2:

*City: *

*Country: *

United States of America United States Minor Outlying Islands United Kingdom Canada Australia New Zealand Afghanistan Albania American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Aruba Austria Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgystan Lao Latvia Latvia Lebanon Lesotho Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia (FYR) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea Spain Sri Lanka Sudan Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Swaziland Sweden Switzerland Switzerland Syria Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe

*State: *

*Zip: *

How did you hear about online registration?

Primary Parent's, or Guardian's Name: *

Primary Parent's, or Guardian's Phone: *

Parent's, or Guardian's Name:

Parent's, or Guardian's Phone:

Emergency & Medical Information

Primary Emergency Contact: *

Primary Emergency Contact Day Time Phone: *

Primary Emergency Contact Night Time Phone: *

Alternate Emergency Contact: *

Alternate Emergency Contact Day Time Phone: *

Alternate Emergency Contact Night Time Phone: *

Family Doctor's Name: *

Family Doctor's Phone: *

Allergies? (If yes, please list.) *

Asthma? (If yes, does child carry inhaler? Yes/No) *

Does your child have any medical restrictions? (If yes, please list.) *