Camper Online Registration

Full Name *

First Name

Middle

Last Name

Age*

Birthdate*

Please list the grade you will be entering Fall 2017*

Address *

Address Line 1

Address Line 2

City

State/Prov.

Postal Code

Home Phone*

Cell Phone

Email*

Are you a first time camper to Koronis?* Yes
No

Please list any friends you would like to share a cabin with

Please list any friends you are bringing to camp for the first time

Medical Form (required) Health History

Chicken Pox* Yes
No

Bed Wetting* Yes
No

Asthma* Yes
No

Diabetes* Yes
No

Ear Trouble* Yes
No

ADD/ADHA* Yes
No

Allergies

Insect Bites* Yes
No

Please list any medication allergies *

Please list any food allergies *

Immunization Record (record date of last immunization)

Polio*

Measles*

Diphtheria*

Mumps*

Pertussis*

Tetanus*

State last illness and when *

Please list all medications your child is currently taking and any special activity limiations *

Insurance Information

Health Insurance Company*

Policy #*

Emergency Contact Name*

Emergency Contact Phone*

Medical Release In consideration of the benefits derived from Koronis Bible Camp. I hereby give my permission for the child to attend and voluntarily waive any and all claims against its sponsors, directors, and officials for any and all causes that may arise from activities of the camp. if medical attention is necessary, I agree to be responsible for all costs not covered by my insurance company. In case of emergency, I hereby give permission to the Physician, selected by the Camp Program Director, to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child named above.

Photo Release I agree that any portraits or video of the camper taken at camp may be used by Koronis Bible Camp or their assigned agents for advertising and promotional literature. I waive my right to inspect or approve the finished product or copy.

Please answer yes to agree to the medical and photo releases as stated above.* Yes
No

Signature or Parent/Guardian *

Camper Registration Form

Camper Fees: $331