2020 Registration

Camp Red Oak Springs

Where life long friends and Memories are made.
Camper Information

Please complete ALL questions.
Camper's Name *

First Name Last Name
Gender *

MALE FEMALE

I want to attend session(s) *

Session ONE $ 145.00

June 7 - 12, 2021 Director: JWill Simms

Session THREE $ 145.00

June 21 - 26, 2021 Director: Sterling McDonald

Session FOUR $ 145.00

June 27 - July 3, 2021 Director: Keith Sunday

Session FIVE $ 145.00

July 5 - 10, 2021 Director: Tony Fitzgerald

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Total $ 0.00

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Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Grade completed *
Camper T-Shirt Size *
A t-shirt is included in the registration fee. Please select the desired size for your camper.
Camper Health Information

To help us better care for your camper, please be specific and accurate as possible.
Does you camper have any FOOD allergies? *

YES NO
List FOOD allergies
List any FOOD allergies camp needs to be aware of.
Prescription Medication

All medicines must be in the original container with original pharmacy label with camper's name. All over the counter medicines must be in store packaging. We cannot accept any medication in plastic bags or pouches.
Does camper have a prescription(s) or over the counter medication to give to the nurse. *

YES NO
Please list all medications camper will take during their session: *
All medicines MUST be in the original container and with original pharmacy label with camper's name. All over the counter medicines MUST be in original store packaging. We WILL NOT accept any medication in plastic pouches.
Does camper have any medical condition camp needs to be aware of: *

Yes No
If yes, please explain: *
Please describe medical condition(s).
Camper is current on all Immunization shots and boosters. *

YES NO
Year of camper's last tetanus shot *
Parent/Guardian Information
Name *

First Name Last Name
Address same as camper: *

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
E-mail *
example@example.com
Emergency/Alternate Contact Information
Emergency Contact's Name *

First Name Last Name
Relationship *
If other, please describe relationship to camper: *
Please explain relationship to camper
Phone Number *

Area Code Phone Number
Swimming Policy

If your camper is unable to swim or has difficulty swimming, a life jacket is required. The life jacket MUST be provided by the parent/guardian. If not, the camper may not be eligible to swim. Swim time is schedule daily during each session. (weather permitting)
I give permission for my camper to participate in a scheduled swim time. *

YES NO
Medical Release and Authorization
As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Camp Red Oak Springs and its affiliates including Directors, Counselors, and Staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp session.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the life and limb of the named minor child, in my absence.
Medical Release and Authorization *

I AGREE
Photo/Video Release

If given permission, camp may use your camper's image for publicity purposes.
I give permission for Camp Red Oak Springs to use photos/videos of my camper. *

YES NO
PAYMENT

Please select the appropriate form of payment.

Camp Red Oak Springs

Camper Information

Camper Health Information

Prescription Medication

Emergency/Alternate Contact Information

Swimming Policy

Medical Release and Authorization

Photo/Video Release

PAYMENT