LUTHERAN CAMPFORMATION
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Welcome!
About Lutheran Campformation
Counselor Application
Camper Registration
Counselor Registration
Adult Leader Registration
Camp Pinerock
Student Information
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Indicates required field
Student Name
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First
Last
Grade (Fall 2022)
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Gender
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Student Birthdate
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(--/--/----)
Student Cell #
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T- Shirt Size
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Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Have you previously attended Campformation
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Yes
No
Which congregation will you be attending with?
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Residential Address
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Line 1
Line 2
City
State
Zip Code
Country
Parent/Guardian Name
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First
Last
Parent/Guardian Phone Number
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Parent/Guardian Email
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Parent/Guardian Name
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First
Last
Phone Number
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Parent/ Guardian Email
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Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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Health and Medical Information
Student's Primary Care Physician Name
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Student's Primary Care Physician -Phone
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Health Insurance?
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Yes
No
If yes, name of Insurance Carrier
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Policy Holder
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Group Number
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Please check any health conditions your child has
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Asthma
Heart Disease
Diabetes
Bleeding/Clotting Disorder
Musculoskeletal Disorder
Seizures
Bedwetting
Constipation
Sleep Walking/ Disturbances
Fainting
Frequent Headaches
Depression/Anxiety
ADD/ADHD/Etc.
NONE of the Above
Please list any other current medical condition or heath concerns we should be aware of ( if none, type NONE).
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Special Dietary Needs (if none, type NONE)
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Date of last Tetanus Shot
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Required (--/--/----)
Does your child have any activity restrictions?
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Yes
No
If yes, what activity restrictions?
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Allergies
List any known allergies with the reactions (food, medications, etc.) If none, type NONE.
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Medications
Any prescription OR over-the-counter medication must be left with the Lutheran Campformation Nurse. Medicationmay only be left at camp if the medication is in the
original
over the counter or prescription container and has detailed written instructions for administration. Medications in a baggie or similar container will be refused.
For the comfort and care of minor illness/ injury, my child may receive the following:
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Tylenol
Ibuprofen
Tums/Pepto
Antihistamine
Decongestant
Cough Drops
Peroxide
Calamine Lotion/Hydrocortisone
Topical Anesthetic
ANY listed above
NONE listed above
Medical and Liabilty Release Statement
This health history is correct so far as I know. I hereby give permission to camp medical/first aid personnel or Camp Director to provide routine health care and emergency first aid; to release any records necessary for treatment or insurance purposes, and to provide or arrange necessary transportation. I understand that my insurance information will be given to any healthcare providers, but that I will ultimately be responsible for any medical charges in the case of illness or injury while my youth is participating at Lutheran Campformation. In the event I cannot be reached in an emergency, I hereby give the permission to the physician selected by the Camp Director to secure and administer treatment, including hospitalization, for the person named above. I understand that the camp health supervisor is present 24 hours a day, but a physician is not present. I agree to travel to Prescott to attend to my child and/or to transport my child home for fever, vomiting or as deemed necessary by the Camp Dean.
I understand that participation in this event is not without risk to my child because of the group nature of the event and the unpredictable behavior of any group, even when managed with the greatest amount of care. I understand that all reasonable safety precautions will be taken at all times by Lutheran Campformation. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to not hold Lutheran Campformation, its leaders, employees, volunteers or your home church liable for damages, losses, diseases, negligence, or injuries, or death incurred by my youth.
Covid 19-Policy as of May 2022
This policy applies to every person attending and participating in Campformation, during the summer session from July 2-8, 2022. Staff training begins July 2 and the camp session starting July 3, 2022
Testing for Covid-19
All persons regardless of vaccination status, will provide a negative "at home" test, on the day of camp. Adult supervisors from each church will have "at home" tests available prior to departure for camp. Tests will be administered by an adult supervisor and the results recorded, indicating a negative result.
While at Camp
Any person, while attending camp, must report to the camp nurse if they experience any signs of Covid-19. The nurse will administer a Covid-19 antigen test at that point. If the antigen test is positive, the person will be required to quarantine and because of the required amount of time for quarantine, there is a good chance the infected person will be sent home.
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Campers will be quarantined until a parent or guardian picks up the camper. There will be no refund of camper fees in this circumstance.
Adults and staff counselors will need to arrange for your own transportation, should you test positive for Covid-19 and need to leave camp. You will also be required to quarantine if you are in camp and waiting for transportation to pick you up.
This is a living document and will be updated as conditions or requirements change
Phote Release Statement
Lutheran Campformation takes photos and videos throughout the week with the intent to celebrate the mission of Lutheran Campformation with an end of the week video. These pictures and videos MAY be used in social media and website promotion, but will not include any information on the individuals pictured (names, church affiliation, etc.). By submitting this form, you acknowledge this photo release statement and agree.
(Any concerns with the photo release statement can be brought to the attention of your church representative.)
Payment Information
All payments for Campformation will be handled through your home congregation. Please submit your payment to your pastor, youth director, or your church office by the deadlines that are specified by your home congregation.
All checks should be made payable to your home congregation.
Agreement - Electronic Signature
By checking YES below, you are confirming your agreement to the terms outlined above and that the information provided is complete and accurate.
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Yes
Parent/Guardian, please type your full first and last name. This serves as an electronic signature confirming your agreement to the terms outlined above and that the information provided is complete and accurate.
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Submit
Home
Welcome!
About Lutheran Campformation
Counselor Application
Camper Registration
Counselor Registration
Adult Leader Registration
Camp Pinerock