Camp Kodiak Registration Form 2012
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Camper's Name
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Camper's E-mail
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Registering for
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July 1 - July
28 (4 Weeks)
July 29 - Aug
19 (3 Weeks)
July 1 - Aug
19 (7 Weeks)
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Age as of July 1st
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Date of Birth (Month/Day/Year)
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Height
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Weight
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Address
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Phone
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Parent Email *
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Confirm *
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Father's Name
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Father's Bus. Phone
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Father's Cell Phone
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Father's Address (if different than camper)
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Mother's Name
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Mother's Bus. Phone
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Mother's Cell Phone
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Mother's Address (if different than camper)
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Emergency Contact
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Relationship to Camper
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Emergency Contact Phone
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Emergency Contact Cell
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Doctor's Name
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Doctor's Phone
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OHIP # / Medicare # / Health Insurance
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Medical and/or Nutritional Alerts
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Medications to be administered at camp
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Why is the medication being taken ?
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Are there any changes in medication while at camp?
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Is this camper more or less active than others his/her age?
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Bedwetter? If so, how often?
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Usually awaken for washroom? If so at what time?
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Bad Dreams? Type? Frequency?
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Can camper sleep on a top bunk?
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Fears? (Dark, water, animals, insects, etc.)
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Friends: (Boys/Girls; many/few; ages; Do they call?)
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Describe social interactions with peers
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Describe interactions with adults
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Major changes happening in this campers life? (Divorce, death, illness, new baby, change of school, etc.)
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Will s/he be missing any significant events while at camp?
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Describe previous camp experience (name of camp, dates, successes, challengers)
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Athletic ability
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Swimming ability (level achieved)
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Hobbies, sports, interests
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Strengths
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Weaknesses
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What is this youngster's attitude towards attending camp?
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What goals do you have for your camper this summer?
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Academics: Would you like your camper to participate in:
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Option 1
(Tutoring)
Option 2
(Electives)
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School
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School Phone
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School Address:
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Grade
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Type of Class
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Teacher
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Guidance Counselor
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Is this youngster receiving outside counseling?
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Why
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From whom?
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Address & Phone
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Please describe any behavioural issues at school or in the neighborhood
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Additional information/comments
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This section is to be completed where there is a divorce or separation:
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Who has custody of the camper?
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Are there any restrictions with regard to visitation rights? Please provide full details:
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EMF Contact Form