Camper Application Camper Application Camper Application Camper's Full Name * First Name Last Name Preferred Name Age Birthday MM DD YYYY Grade Completed Sex Male Female Shirt Size Youth S Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL Adult 2X Adult 3 X Other Parent/Guardian * First Name Last Name Mailing Address * City/State/Zip * Email * Phone (###) ### #### Emergency Contact * First Name Last Name Phone (###) ### #### Church Name * Address * Pastor's Name First Name Last Name Pastor's Telephone (###) ### #### My child has permission to participate in all camp activities unless stated otherewise here: Yes No My child has permission to be included in photographs and videos taken by camp personnel for use in promoting camp/facilities in brochures, videos, and or/newspapers. Yes No Please select the week(s) your child wille attending. Week 1 (Day Camp): June 9-13 | Grades 1-6 Week 2 (Overnight): June 15-19 | Grades 1-3 Week 3 (Overnight): June 22-26 | Grades 4-6 Week 4 (Overnight): July 6-10 | Grades 6-8 Week 5 (Overnight): July 13-17 | Grades 9-12 Payment Options Please select the method that you will pay. Online Payment I will pay in full at registration. I have a sponsorship from my church. I am paying for an additional week. I am paying for an additional child. Parent/Guardian Signature By typing my name below, I agree this serves as my electronic signature. Camper Health Form 2025 Camper's Full Name First Name Last Name Date of Birth MM DD YYYY Height (ft) 3 4 5 6 Height (in) 0 1 2 3 4 5 6 7 8 9 10 11 Weight Age on 1st Day of Camp Parent/Guardian Name First Name Last Name Insurance Information Name & address of Personal Insurance Company or Organization Providing Benefits or Services Policy or identification number(s) Please include all letters and numbers in policy number. Member ID Group Number Name of member of household through whom benefits/services are available Name of Family Physician First Name Last Name Physician Office Telephone (###) ### #### Date of Last Tetanus or Booster MM DD YYYY Tetanus immunization should be current before a child attends camp. Please indicate any special needs of which the camp staff should be aware (sleepwalking, bedwetting, night terrors, other illnesses, etc.) Is the camper bringing any medication to camp? Yes No If yes, please print and fill out the "Medicine Release Form" at the bottom of the page and place in a sealed bag with ALL medications. All medication should be in the original container. Medication not provided in the original container cannot be administered at camp. All medication should be given to the Camp Nurse or Camp Director at the time of registration. Please do NOT send first-aid supplies: (Aspirin, Tylenol, cold remedies, etc.) to camp with your child. The Camp Nurse keeps these supplies on hand. The following persons have my permission to pick up my child from Camp Lakeside 1) Name First Name Last Name Relationship Address Phone Number (###) ### #### 2) Name First Name Last Name Relationship Address Phone Number (###) ### #### 3) Name First Name Last Name Relationship Address Phone Number (###) ### #### No other persons have permission to pick up my child. Parent/Guardian Signature By typing my name below, I agree this serves as my electronic signature. Thank you! Medicine Release FormPlease print, fill out, and bring to check-in with all medications in a sealed bag. Medicine Release Form