2023 Camper Registration

Parent / Guardian Information

Parent / Guardian's Full Name

Address

This address will receive a confirmation email

Phone

Secondary Phone Number

Emergency Contact Information

Name of Emergency Contact (Other than parent/guardian)

Relationship

Emergency Contact Phone Number

Alternate Emergency Contact Phone Number

Camper Information

Camper's Name

I want to sign my child up for:

Junior Camp (July 10-15) For 2nd-7th Grade Completed Senior Camp (Aug 7-12) For 6th-12th Grade Completed Both Camps

Sex

Male Female

Birthdate

If you selected "other" because your church was not listed, please list the church and town here:

T-Shirt Size [Selected size may not be available if registering after June 22 (JR Camp) and July 20 (SR Camp).]

Youth: Small Youth: Medium Youth: Large Small Medium Large X-Large XX-Large XXX-Large

One Bunk Partner Request:

Medication Information

Primary Doctor's Name

Primary Doctor's Phone Number

Tetanus Booster Shot (If the shot is not up to date, one may be given if needed.)

List Allergies (Seasonal, Food, Medicines, Insects)

Pre-existing Medical Conditions (diabetes, asthma, heart problems, seizures, etc.)

Restricted Activities

Medication

MEDICATION POLICY:
Medication brought to camp MUST be checked in with the camp nurse ar registration. All prescription medication MUST be in the original container with the camper's name, name of medication, and directions clearly marked on the pharmacy label. PLEASE PUT ALL MEDICATION AND ANY INSTRUCTIONS IN A ZIP LOCK BAG AND GIVE TO YOUR CHURCH SPONSOR SO IT CAN BE TURNED INTO THE NURSE AT CAMP. Over-the-counter medication can only be provided by the camp nurse and staff. The camp nurse has non-prescription medicines in the event of a minor illness or injury.

1st Medication Name:

1st Medication Dosage:

1st Medication Frequency:

2nd Medication Name:

2nd Medication Dosage:

2nd Medication Frequency:

3rd Medication Name:

3rd Medication Dosage:

3rd Medication Frequency:

4th Medication Name:

4th Medication Frequency:

4th Medication Dosage:

Any other medications:

Primary Medical Insurance

Insurance Company Name

Insurance Company's Phone Number

Policy Holder's Name

Medical Policy Holder Relationship to Camper

Policy ID #

Member ID #

Notice & Permissions

These items are not allowed at camp: cell phones (unless given special permission by CNW Staff), radios, CD or MP3 Players, hand-held video games, questionable magazines, tobacco, liquor, drugs, knives, guns, or fireworks. If a reasonable suspicion exists of a camper having any of these items, his/her backpack or luggage may be searched.

“I give permission for the above-named individual to attend Camp Northwest. I agree to support Camp Northwest in their dress and conduct regulations for my child while at camp. I also give permission to use photos including this camper in camp publicity."
“In case of a medical emergency, I understand every effort will be made to contact parents or guardians of campers. In the event I cannot be reached, I hereby give permission to the physician selected by Camp Northwest to hospitalize, secure proper treatment for, and to order injection, anesthesia, and/or surgery for the above-named individual. I also give my permission to the camp nurse and staff to give non-prescription medications in the event of a minor illness or injury.”
“I agree to release any records necessary for treatment, referral, billing, or insurance purposes. I also affirm that the medical information and insurance coverage on this form is complete and correct.”
“I voluntarily waive the claim against Camp Northwest, camp personnel, or other person(s) transporting my child, against all liability, claims, damages, attorney fees, expenses arising out of or in connection with any activities of the above organization”

Camper's Name

Type Name To Accept Parental Permission Agreement

Payment

A processing fee of $1.80 will be added for each downpayment paid online. Your church sponsor will collect the rest of the payment from you. Each church will pay the remaing balance at registration on the Monday of camp. The downpayment is nonrefundable with a couple exceptions. This reserves a spot for your child to attend camp.

You now also have an option to pay the full registration price, but there is a processing fee of around $8.00 for this convenience.

Camper Payment (options)

Camp DVD

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2023 Camper Registration

Description

Please Fix the Following