Beaver Creek CAMP 2023 Final

Beaver Creek Camp Registration Form 2023

Thanks for registering online for Camp!

MAIL IN 1/2 of your PAYMENT BY JUNE 15th

(other half day of camp)

Post Office Box 2152

East Liverpool, OH 43920

http://beavercreekcamp.com/campdescriptions.html

Brittany Ingledue

brittanyingledue@icloud.com

(330) 708-9661


How many children are you registering?

General Registration Information

List Each Camper Attending Per Line (Name, Age, Birthdate, Grade Completed)
Full Name of Camper's Parent or Guardian
Camper's Parent's Email Address
Camper's Parents Home Phone
Camper's Parents Cell Phone
Camper's Parents Work Phone
Camper's Address (include City, State, & ZIP)

Emergency Contact if we can't contact the Parent or Guardian

Full Name of Emergency Contact
Relationship to Family
Cell Phone of Emergency Contact
Home Phone of Emergency Contact

WHICH CAMP SHOULD I CHOOSE? (Left Click for Drop Down Menu Below)

CAMP CHOICE FOR 2023!
Name of Roommate (leave blank if it doesn't apply)
Roommate's Phone Number (leave blank if it doesn't apply)

Church Information

Name of Home Church
Home Church Phone
Home Church Address
Amount of Fee Reimbursement from Church (leave blank if it doesn't apply)

Camping Experience & Relevant Personal Issues to be aware of in confidence
The following information is designed to assist the camp director and counselors in most constructively grouping, program planning, and counseling with your camper. Only those directly responsible for your camper will have access to this information.

Check Any that Apply to Your Camper		First Time Camping Troubled Family Background Deceased Parent (s) Complicated Family Dynamic Difficulty Connecting with Other Students Self Esteem Issues (needs encouragement) Bedwetting Issues Nervous About Camping with New People Anxiety About being away from Home Have attended Beaver Creek or another Camp Other Issue I'd like to talk to you about
Any physical disabilities or medical conditions
Other Confidential Information
What is your camper excited about
Your hopes for your camper

General Medical Background & Emergency Permissions
Describe any medical problems for which treatment is or might be necessary while at camp, including any prescription or over-the-counter medicines to be taken. (please state dosage required)

Describe any previous serious illness, operations, or injuries
Describe medical problems and treatment HERE
Does your camper have a severe reaction to Poison Ivy? (Describe)
Describe any needed restrictions on activities or special diet
Check any of the following problems the camper has had		Allergies Asthma Bleeding Problem Bed Wetting Bowel Problem Convulsions Concussion Diabetes Frequent Nosebleeds Heart Problem Insect Sting Reaction Sleeping Disorders Other (Please explain below)
Other concerns that we should know about?
Name of family physician
Physician Office Number
Camper covered by medical insurance? YES or NO
Medical Insurance Info: Policy Number, Address, Phone

Permission for Medical Care
In Case of an Emergency: I understand that every effort will be made to contact the parent/guardian of a camper or minor staff member, or next of kin of an adult staff member, in case of a medical emergency. In the attempt that such attempts are unsuccessful, I hereby authorize the staff at Beaver Creek Camp to obtain medical care for the person identified in this form, and hereby authorize the physician and/or hospital selected to provide emergency treatment for the person identified in this form.

EMERGENCY MEDICAL CARE FOR MY SON OR DAUGHER (YES or NO)
PARENTAL INITIALS FOR MEDICAL PERMISSION
YES or NO to give your child Tylenol or Benedryl

T-Shirts & Pictures

May we include pictures of your camper in photographs that we post on our camp website? (No camper names are provided.) Check YES or NO
Anonymous Pics may be included with Camp Media YES or NO

Select how many shirts you like to buy		1 Shirt ($15) 2 Shirts ($30) 3 Shirts ($45) 4 Shirts ($60)

Select all shirt sizes that apply to your order		child 6 - 8 child 8 - 10 child 12 - 14 adult small adult medium adult large adult XL adult XXL


Other Questions, Comments?