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