LIT Camp Registration 2019

Name*

Address*

Street Address City Province Postal Code

Birth date (d/m/y/)*

Age*

Parent/Guardian name*

Parent/Guardian E-mail address*

Parent/Guardian Address (if different from above)*

Home Ph #*

Work Ph #

Cell Ph #

I give permission for my child to be photographed/videotaped for use in marketing materials*

Yes
No

Any and all info on this form is for the sole use of Camp Wohelo, it is not given out or sold.

Is there are any restrictions as to who may pick up your child and/or any custody issues pending?*

Emergency contact*

Name	Phone	Relation

Second Emergency contact*

Name	Phone	Relation

A copy of Health cards for each person must be attached to this form, or be brought with you to camp.

Doctor’s name*

Doctor's Phone Number

List allergies and care instructions*

List all medical conditions, mental, emotional, physical and behavioral challenges that your child may have including, skin conditions, asthma, bed-wetting, epilepsy, diabetes, heart conditions, hyper-activity, etc.*

Will your child be on medication*

Yes
No

Date of last Tetanus shot (enter date or comment)

Comment

Special diet

List all medications

Child’s swimming ability*

Permission to go offsite with staff, eg. a hike*

Yes
No

Cabin mate preferred

Where did you hear about Camp Wohelo? been before, a friend, an ad, a brochure( where did you get it?) or other (please be specific)*

Permission to administer the medications, prescription and/or OTCs that you send for your child.*

Yes
No

All medication, prescriptions and/or over the counter (OTC may include gravel, Tylenol, Benadryl, etc.), must be brought by the camper, be in the original container and given to the camp medic upon arrival.

In case of medical emergency, I understand that every effort will be made to contact the parent or guardian of the camper. In the event that I cannot be contacted, I hereby give permission to the physician selected by the Director to hospitalize/secure proper treatment for my child as named above. I understand that in an emergency, my child maybe transported in a personal vehicle and I hereby waive my right, and that of my child, to any claim against Camp Wohelo, its employees or volunteers.*

Yes

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LIT Camp Registration 2019