Camp Caudle Registration Form 2025

Camp is June 29 - July 4, 2025. Please complete this form and submit by June 15. Camper spots are awarded on a first come, first served basis, and we are expecting to fill up the available spots quickly.The form will only hold your child's spot when it is submitted with a paid deposit. If you are requesting a scholarship, go ahead and complete your registration, and mark "yes" when asked if you need financial assistance. This registration form is for students who have completed 2nd-8th grades and for our junior campers accompanying parents who are volunteering at camp.

Camper Name

Birthdate

Gender

Male Female

Last grade completed

2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade Below 2nd grade & parent is an approved volunteer

Guardian's Name

This address will receive a confirmation email

Phone

Address

Requested Cabin Mate (not guaranteed)

Camper t-shirt size (included in price of camp)

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large

Payment - $300 to https://pushpay.com/g/arcentralchurch?src=hpp (copy into your browser) - $150 deposit due at time of registration. Balance due by 6/15/25. Put Camp in the Memo box. Junior campers attending with parents volunteering - payment - $50 to https://pushpay.com/g/arcentralchurch?src=hpp by 6/15/25 for children over 2 yrs. (Highlight the link address and click on it.) $0

I will need financial assistance to cover the cost of camp.

Yes No

Health Form

Emergency Contact

Phone

Additional Contact in the event that 1st emergency contact cannot be reached

Phone

List known allergies (NA if none)

List any special dietary needs/restrictions (NA if none)

Medical Insurance Information - please bring a copy of the front and back of your insurance card to camp

Camper is covered by family medical/hospital insurance

Yes No

Insurance Company

Policy Number

Subscriber

Insurance Company Phone Number

Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Signature of Custodial Relationship Parent/Guardian __________________________________________________________________Date: _____________________________ to Camper: _________________________

General Health History - Check "Yes" or "No" for each statement. Explain "Yes" answers below.

Ever been hospitalized?

Yes No

Ever had surgery?

Yes No

Have recurring/chronic illnesses?

Yes No

Had a recent infectious disease?

Yes No

Had a recent injury?

Yes No

Had asthma/wheezing/shortness of breath?

Yes No

Have diabetes?

Yes No

Had seizures?

Yes No

Had headaches?

Yes No

Wear glasses, contacts, or protective eyewear?

Yes No

Had fainting or dizziness?

Yes No

Passed Out/Had Chest Pain during Exercise?

Yes No

Had Mononucleosis (mono) in the last 12 months?

Yes No

Have problems with periods/menstruation?

Yes No

Have problems with falling asleep/sleepwalking?

Yes No

Ever had back/joint problems?

Yes No

Have a history of bedwetting?

Yes No

Have problems with diarrhea/constipation?

Yes No

Have any skin problems?

Yes No

Travelled outside the US in the last 9 months?

Yes No

Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel.

Mental, Emotional, and Social Health: Check “Yes” or “No” for each statement.

Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?

Yes No

Ever been treated for emotional or behavioral difficulties or an eating disorder?

Yes No

During the past 12 months, seen a professional to address mental/emotional health concerns?

Yes No

Had a significant life event that continues to affect the camper’s life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)

Yes No

Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.

Health Care Providers

Name of camper's primary care physician

Phone

Name of dentist

Phone

What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.

Electronic Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Camp Caudle Registration Form 2025

Description

Please Fix the Following