3784 Church Camp Road

Iowa Park, Texas76367

(940) 855-4182

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Camper’s Last NameCamper’s First Name

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Home Phone NumberBirth DateGenderAge

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Parent or Guardian’s NameWork PhoneCell Phone

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Mailing AddressStreetCityStateZip

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Camper’s SchoolChurch You Attend/City

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Is Camper Coming With A Friend?Friend’s Name

Grade Completed (circle one) K1st2nd3rd4th5th6th

Shirt Size (circle one) Child Small Child Medium Child Large Adult Small Adult Medium Adult Large

Check the Day Camp(s) Session Choice:

___June 15 – 19 ___July 6 – 10 ___July 20 – 24

___June 22 – 26 ___July 13 – 17 ___July 27 – 31

___June 29 – July 3

Cost: $100 per camper

Discount for siblings:First camper regular price,$10 offon each additional sibling

Discount for attending multiple sessions: $10 off for additional session

(Maximum allowable discount is $20)

Sugar Shack Card:You may buy cards in increments of $5 for your child to be used at the Green Barn and Sugar Shack Concession Stand. This will prevent money being lost.

Tuition Amount$______

Sugar Shack Card$______

Total Amount$______

Medical Information:

Family Physician______Phone ______

Allergies ______

Is your child currently taking any medications? __yes __no. Please list dosages and times

Medication ______Dosage ______Time ______

Please list any medical conditions or recent surgeries your child has had. ______

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Family Physician ______Phone ______

Insurance Provider ______
Address ______

Policy # ______

It is recommended that you attach a photocopy of your medical insurance card.

Non Prescription Medications

The following non-prescription medications and treatments are available for you child in our first aid station. Please circle any of these medications if you DoNot want your child to receive them.

TylenolPepto BismolBand-aids

RobitussinBenadrylSwimmer’s ear

Parental Permission:

My child has my permission to attend Camp Chaparral Day Camp and to participate in ALL activities. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the adult leader, to order injection, surgery, or any other medical treatment deemed necessary to insure the well-being of the above named child. I also authorize camp personnel to transport the above named camper in the case of an emergency. I agree not to hold liable Camp Chaparral or its staff in the case of an unforeseen event.

I understand that as a participant, my child may be photographed or video taped during normal camp activities and these photos may be used in promotional materials. I also understand that Camp Chaparral cannot be responsible for lost or broken items, and that unclaimed items will be donated to charity at the end of the summer.

**I agree to check my child for head lice BEFORE sending them to Day Camp**

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Parent/Guardian SignatureDate