Rainbow Glacier Christian Camp

Registration and Health History Form 2008

Please fill out a separate registration form for each camper

Please mail to P.O. Box 432, Haines, Alaska 99827 with payment or scholarship request

 

    Name                                                                                                                        Birth date                               Age at camp                        

                  Last                              First                      Middle

    Home Address                                                                                                                                                                                                          

                            Street or PO number                                                                                 City                            State                  Zip 

 

    Grade entering fall 2008            Gender:  Male    Female    Camper’s email address                                                                                          

 

    Custodial parent(s)/guardian                                                                   Guardian’s email address____________________________________

 

    Home Address                                                                                                                                                                                                          

If different from above Street or PO number                                             City                             State                  Zip  

 

    Home phone                                                           Work Phone                                          Cell phone                                                                                     

 

    If not available in an emergency, notify:                                                                                                                                                                       

 

    Relationship                                                                                                                                                                                                                

 

    Home phone                                                           Work Phone                                          Cell phone                                                                             

                 

    Local church affiliation if any                                                                                                                                                                                        

 

2008 SUMMER CAMP SCHEDULE:          (Please circle one)

o        June 16-20          Elementary Camp #1  (Ages 9-12)                                       $150

o         June 23-29          Junior High Camp #1  (Ages 12-14)                                $165

o      June 30-July 2      Primary Camp  (Ages 6-8)                                                  $100

                           *This camp is a DAY CAMP…with the option for campers to stay overnight if desired or if campers are from outside of Haines. If  campers are needing ferry transportation, they may stay @ RGC overnight until the ferry on the morning of the 3rd.            

o        July 7-11              Elementary Camp #2  (Ages 9-12)                                    $150

o        July 14-20           Senior High Camp  (Ages 14-18)                                       $165

o        July 21-26           Junior High Camp #2 (Ages 12-14)                                   $165

 *Cost DOES NOT INCLUDE TRAVEL by ferry from Juneau to Haines and back.

NOTE: RGC will provide transportation to and from the Haines ferry terminal to the camp.

REFUNDS: If cancellation occurs at least 2 weeks prior to the start of the registered camp, a full refund will be provided.

 

Please makes checks payable to: RAINBOW GLACIER CAMP

Mail to:  Rainbow Glacier Camp - PO Box 432 – Haines, AK – 99827

Phone: (907)766-2127; Email: rainbowglaciercamp@gmail.com

 

    Discount Program: BRING 2 FRIENDS AND GET 50% OFF…BRING THREE AND COME FREE!!! 

    Name of friend(s):                                                                                                                                                      

    Family Discount: Sisters/brothers attending camp within the same summer may take $20 off of the registration fee.

    Cost after discount/s                                                                                   $                                        

    Amount Enclosed                                                                                       $             

    Amount donated to the scholarship program                                                $             

    Amount requested for scholarship                                                               $             

 

                *Scholarships may be available, but are limited (dependent upon need).  Please contact RGC for     

                     information/application.

 

*I would like to be in the same cabin as __________________________

(We may not be able to honor the request if it is made too close to the date of camp.)

 

 

 

Important – These boxes must be complete for attendance

 

 

Text Box: Camper’s Covenant I promise to follow the rules while at camp and during travel time. I will respect the counselors, chaperones and other staff. I will respect other campers, camp property and myself.   Signature of camper_                                                                              Date                                         

        

 

 

 

Text Box: Custodial parent/guardian I give permission for my child named above to participate in all camp activities, except as noted, to be transported in private or camp vehicles; and will hold the camp, its agents or employees harmless in case of injury or illness. This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I herby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. I also give permission for my child’s photo or video to be used for publicity for the camp. Signature                                                                                                  Date                                                

 

 

 

 

 

 

 

 

 

Text Box: Pastor, church elder or other adult I will pray and support this youth as they attend Rainbow Glacier Christian Camp.   Signature                                                                                                 Date                                                             

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration and Health History Form 2008

 

    Name                                                                                                  Social Security Number                                                                       

                  Last                              First                       Middle

 

Medical Insurance Carrier:                                                                                                                                                     

 

Policy number:                                                                                                                                                                       

 

Name of family physician:                                                                                       phone                                                       

 

Name of family dentist:                                                                                           phone                                                       

 

Date of last physical exam:                                                     Last date of Tetanus Shot                                                          

 

 

    ALLERGIES – MEDICAL, FOOD OR OTHER – including insect stings, hay fever, asthma, animal dander, etc.

 Text Box: Please mark if the following apply to the person: Eating disorder Emotional difficulties Asthma Frequent headaches Diabetes Wear glasses or contacts Heart Problems Heart murmur Convulsions Bedwetting Sleep walking Skin problems ADD or ADHD Abnormal menstrual history  Other:                                                                                                                                                                                                                                    Please list any hospitalizations, operations and/or serious injuries (please give dates):                                                                                                                                                                                                                                                         List any chronic or recurring illnesses:                                                                                                                                                                                                                                                                              Please provide any additional information about behavior or physical, emotional, or mental health about which camp should be aware:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

    Please list                                                Describe reaction and management of reaction

 

                                                                                                                                                                                      

 

                                                                                                                                                                                       

 

                                                                                                                                                                                       

 

  *Please list any food restrictions here: ______________________________________________________________________

 

 

 

 

 

 

                                      

 

 

Text Box: I authorize camp to administer the following as needed: Tylenol, Ibuprofen, 1% Hydrocortisone Cream, Topical Benadryl Signed:                                                                                                   Date                                                                       

 

Text Box: MEDICATIONS BEING TAKEN: Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp including travel days. Keep it in the original packaging/bottle that identifies the prescribing physician. Please do not send non prescription drugs to camp. This child takes no medications on a routine basis or This child takes medications as follows: Med #1                                   Dosage                    Specific times taken each day                                                                                    Reason for taking                                                                                                                                                                                     Med #2                                   Dosage                    Specific times taken each day                                                                                    Reason for taking                                                                                                                                                                                     Identify any medications taken during the school year that participant does/may not take during the summer:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

Text Box: I authorize camp to administer the following as needed: Tylenol, Ibuprofen, 1% Hydrocortisone Cream, Topical Benadryl   Signed:                                                                                 Date                               

 

                                                                

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

    ***After having received these forms, the Rainbow Glacier administration staff will then send a follow-up letter to you with more    

     details about you child’s week at camp (i.e. the what to bring list, travel info, emergency contact info, and a list of who else is coming

     to camp from your community).

 

            THANK YOU!!!

Please mail to P.O. Box 432

    Haines, Alaska 99827