Summer Camp Registration

Summer Camp Registration

NCA Summer Camp Form Preview
  • 2018 Camper Application
  • Address: Phone: +1-715-532-0201
    1500 Port Arthur Road Fax: +1-715-532-9916
    Ladysmith, WI Email: camp@northcedar.net
  •   Session 1:
    July 8 - 21
    Session 2:
    July 22 - August 4
    Session 3:
    August 5 - 18
    Select 'Yes'
    or 'No' for
    each session
  • *Campers will not be allowed to participate in camp activities until the Camper Application and the Medical and Release Form are completed/signed by a Parent/Guardian and returned with a COPY of your medical insurance card (front and back).

    *Campers will be responsible for any and all medical expenses incurred during camp.

    *Space is limited. Online registration can be accessed at www.northcedar.net/camp, or email this form to camp@northcedar.net.

    *Payments can be made online at www.northcedar.net/camp

    *Forms can also be mailed to the above address.

    *If also mailing payment, make checks payable to North Cedar Academy.

  • Camper's Information

  •  -  -
    Pick a Date
  •  -  -
  •  -  -
  •  -  -
  •  -  -
  •  -  -
  • Camper's Health and General History Statement

  • All fields are required below.  If nothing applies, please put "NONE" in the box.  

    Thank you!

  • Epinephrine Pen Use

  • Health Insurance Information

    Please fill out the insurance information below.

    ***If you do not have insurance please write “Self Pay” in each of the boxes.

  •  -  - Pick a Date
  • Fitness to Participate: I affirm that the above camper has no physical, emotional, or mental condition that would affect or be affected by these activities of camp. If there is an activity they should not participate in, I will contact camp@northcedar.net with my child's name and applicable information.

    Insurance Disclosure: I understand that neither NCA nor its insurance policy provide health insurance coverage for campers. I agree that all costs related to camper illness, or sickness, or accident will be billed to me and I will be responsible to pay these costs. I will check with my insurance provider to determine if additional insurance is needed to cover the camper while attending camp or participating in its activities.

    Emergency Epinephrine Use: I allow camp Staff to administer epinephrine via epi-pen to my child in emergency situations while at camp. I hereby agree to save and hold harmless NCA and any of its employees from and against any and all losses, claims, damages, or expenses which may arise as a result of granting this request. This paragraph only pertains to those that marked "Yes" in the Epinephrine Pen Use section.

    Waiver and General Release of Liability and Hold Harmless: In consideration of the camper’s opportunity to attend camp at NCA and participate in its activities, I on behalf of myself and the minor camper for whom I am the parent or guardian, waive and release NCA, its staff, board members, officers, directors, employees, volunteers and agents from all liability of any kind arising from or related to attendance at camp or participation in its activities. This is intended to be interpreted as a broad, general waiver and release. I further agree to indemnify and hold NCA, its staff, board members, officers, directors, employees, volunteers and agents harmless from liability for all claims for personal injury, death or property damage of any kind made by me, my family members, the minor camper for whom I am the parent or guardian or their successors.

    In signing this document, I hereby certify that the above information is correct and give the following permissions:

    • For my child to engage in all prescribed camp activities. I will communicate any restrictions or changes of form information to camp administration via email at camp@northcedar.net . I will make sure to include my child's full name in all correspondence.
    • For the use of photographs and video including my son or daughter to be used in camp publicity.
    • In the event I cannot be reached, I hereby give permission to the physician selected by camp staff to obtain proper medical diagnosis, hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child as named above.
  • Should be Empty:
Now create your own JotForm - It's free! Create your own JotForm