Camp Kee Mo Kee 2009 Registration Form

To Register: Complete both sides of this page, and be sure to sign at the bottom on both sides. If you are registering for more than one week, please complete separate forms and include a deposit for each week (you may make copies of this form as required). For camp J (family camp) you may fill out one registration form for the family, but include a health form for each person. Enclose your $50.00 non-refundable deposit for each registration. For camp J please enclose the entire amount owing. Make cheques and money orders payable to Camp Kee-Mo-Kee. Mail completed form(s) and deposit to:

Camper Information
Camper’s Name: ______
Address: ______
______/ Camp Selected: ______Camp Date: ______
(if camp H please specify Adventure or Jr. Leader)
Date of Birth: ____/____/______(Mon/Day/Year)
Age at camp: _____ Gender: M / F
Contact Information
Parent / Guardian Contact Numbers (while camper is at Kee-Mo-Kee):
Name: ______
Home No.: ______
Work No.: ______
Email: ______/ Name: ______
Home No.: ______
Work No.: ______
Email: ______
Emergency Contact Numbers (if parents / guardians cannot be reached):
Name: ______
Home No.: ______
Work No.: ______/ Name: ______
Home No.: ______
Work No.: ______
Please indicate if someone other than the parent or legal guardian will be dropping off or picking up the camper.
______
Also indicate if there are any custody restrictions, or if there is anyone who should NOT be allowed to pick up the camper:
______/ Cabin requested with: ______
Tax Receipt: Would you like to receive a receipt for registration fees paid? If yes, who should the receipt be made out to?
To:______□ Yes □ No
Photo Release: Your child may be photographed or videoed during their time at camp. Please indicate if photos or videos of your child may be posted on the camp website or used in promotional displays:
□ Yes □ No
Photo CD’s: CD’s will be produced on site for sale to campers. Do you give permission for your child to appear in these photos
□ Yes □ No / Out tripping: Certain special events, hikes and overnight campouts may take place off camp property. Please indicate that your child has permission to participate in offsite activities:
□ Yes □ No
T-shirts: Campers will receive a free t-shirt when registration form is received before April 30. Size requested: ______
Camp T-shirts will be on sale for $10.00 at the start of each session
Privacy: Camp Kee-Mo-Kee is committed to the protection of the privacy of your personal information. Registration and Health Care information collected on this form is used for regular camp operations only and is not shared with other organizations. Health care information may be shared with health care agencies when deemed necessary due to a medical emergency. More details on the specifics of our privacy policy can be found at www.keemokee.com.
I give consent for the collection and use of this personal information: □ Yes

Camp Kee-Mo-Kee reserves the right to send any camper home during camp if necessary. I give permission for my child to participate in the camp program, and I agree to pay the balance of the camp fee by May 31, 2009.

Parent / Guardian Signature: ______Date: ______


Health Care Information Form

Basic Health Care Information
Camper’s Name: ______
Doctor’s Name: ______
Doctor’s Phone: ______/ Height: ______Weight: ______
Health Card #: ______
Version Code: ______(2 letters, only on new health card)
Health History
Please list any past / present illnesses, weaknesses, conditions, injuries or surgery (please date):
Please list any special requests or dietary restrictions:
check if any of the following is true:
camper is:
camper wears:
camper has problems with:
camper can swim in the deep end: / □ diabetic
□ contact lenses
□ nightmares
□ ear infections / □ asthmatic
□ hearing aid
□ bedwetting
□ seizures
□ yes / □ orthodontic equipment
□ homesickness
□ sleepwalking
□ no
Allergies
Please list any allergies and recommended treatment. Also specify if allergies are severe or life threatening:
Additional Notes
·  All medications brought to camp must be in the original container, clearly labeled with camper name. All medications, including both prescription and over the counter drugs, must be turned in to the Health Care Provider at the start of the camp.
·  The Health Care Provider is required to review the information on this form at camp check-in.
·  You must notify the camp Health Care Provider if the camper should be exposed to any infectious diseases in the four weeks prior to camp. Failure to do so may jeopardize the health of other campers and the general operation of the camp session.
·  Be advised a lice check is required during check-in, and will be performed by camp staff. If lice are found, the camper will be unable to attend camp. It is recommended that you check your camper’s head at least a week before camp so that you can begin treatment if lice are found.
·  Feel free to send additional information about your child on a separate sheet of paper, attached to this sheet.
Health Care Release
I hereby certify that the above information is correct. To the best of my knowledge, this camper is in good health and is able to participate in all camp activities. By enrolling this camper, I hereby agree to permit the Health Care Provider or designate to administer such routine medication as he / she may deem advisable. In the event of an emergency, if the camp directors are unable to contact either parent / guardian, the Directors are hereby given permission to act in the camper’s best interest and to seek appropriate medical care. As well I agree to not hold staff or Camp Kee-Mo-Kee liable for accidents or misfortune that may occur to the camper (knowing that every precaution shall be taken by staff to ensure the campers’ welfare and safety). Camp Kee Mo Kee staff are legally obligated to report all cases of suspected child abuse.

Parent / Guardian Signature: ______Date: ______