2007 Makemie Woods Camper Registration Form 

Step 1 of 3
Camper's Name: 
First/MI:     Last:  
Preferred Name:
DOB: 
//		 Sex: 
 Age: 
 Grade in Fall: 
Address:
City:     State:     Zip:
Name of Parents/Guardian: 
Home Phone: Work Phone: 
Cell Phone:  Fax#:
E-mail address:    
Church Membership: (Church Name, denomination)
If parent/guardian not available, call: 
Name:   Phone:   Relationship:  
Buddy Info: This camper can be placed with ONE buddy of the same age and sex, if attending the same camp session. Campers must request each other and ONLY each other. 
Buddy's Name:
T-Shirt Size: (sizes tend to run small) Child's Large -or- 
Adult:
Check here if camper attended Makemie Woods Summer Camp in 2006.
Check here if a 2006 Makemie Woods Physical form signed by a doctor is on file (physicals from previous summers are out of date)
The following are designed to help the Camp Director and counselors do the most effective job of grouping, program planning and counseling for your son or daughter. Only those directly responsible for your child will have access to this information.
Has your child ever been away form home overnight?
Lived in a group outside your home?
First time at summer camp?
Number of summers at Makemie Woods:
Other Camps attended:
How many sisters?   How many brothers?
Do both parents live at home?
Does your child bed wet? If yes, how often?
Does your child swim?   Can he/she swim in deep water?
Can he/she dive?
If registered in canoe camp, does he/she know how to canoe?
Additional information about your child: 

Health History (Check if camper had any condition below and give approximate dates)

Medical Insurance Carrier:

Insurance Policy #

ALLERGIES DISEASES
Ear Infections Hay Fever  Chicken Pox
Rheumatic Fever Poison Ivy Measles
Convulsions  Insect Stings German Measles
Diabetes Penicillin  Mumps
ADD or ADHD*  Other Drugs 
(describe below)		 Asthma
Other (describe below) Food or other allergies 
(describe below)
* If this camper is diagnosed with Attention Deficit Disorder or Hyperactivity, please note in the box below the camper's routine, medications, and what methods have been effective in helping this camper manage in a structured environment.
Comments on any of the above information:

Hospitalizations, operations and/or medications currently taken for chronic conditions:

Chronic/recurring illnesses and/or medications currently taken for chronic conditions

Please describe any handicaps, physical limitations or activity restrictions:

Suggestions from parent/guardian, esp. if the child has special needs, such as ADD/ADHD:

The camp has physician written protocols which instruct the medical personnel in giving campers pain relievers and other over the counter medications, such as Tylenol, Advil, Robitussin, Pepto Bismol, etc. for minor medical conditions. Please list any specific over-the-counter medications you do not wish administered to your child:
Camp Session Selection: (Many camp sessions fill quickly. Please consider an alternative selection.)
First Choice:              If First Choice is full, do you wish for this child to be placed on a waiting list?
2nd Choice:

* This section must be completed. *

Figure Your Cost:  Explanation of Discounts
If dollar amount is not entered automatically based on your 1st selection above, please enter it here:
Camp Fee: $*DO NOT CHANGE		 Camp Fee - Based on Camp Session Selection
Advanced Payments Discount - $10.00 Discount Advanced Payments Discount - If full family payment is enclosed and the family is responsible for half or more of the fee, check the box for discount.
Family Discount - $30 Discount Family Discount - If there is more than one camper from the same family, and this is not the first camper registered, check the box for discount.
Early Discount - $10.00 Discount  (Disabled for '07) Early Discount - If you are registering before April 1st, 2007, check the box for discount.
First-time camper - $10.00 Discount First-time Camper Discount - We're so glad you are coming, we are giving you a discount (on one session only, please). 
Active Duty Military Discount - $10.00 Discount Active Duty Military Discount - If children's parents are Active Duty military.
Winter Camp Coupon Check this box if this camper attended Winter Camp 2006, and is using the coupon on this session
Amount your church is paying: $ Church Payment - Many churches will pay for a portion of the camp fee. Check with your church treasurer. 
Camp Store Account: $

This camper may donate any unspent balance to the Summer Camp Program Fund

 Camp Store - Campers will have an opportunity to purchase souvenirs, sodas and other items.  We recommend $15 - $20 per week stay.  You may choose to donate any balance left to improve the camp's recreation program.
  I prefer to download the confirmation packet
  Please mail the confirmation packet to me. 		Downloading the packet allows you immediate access to the physical form, what-to-bring list, etc.   Please allow 3 weeks for these materials to be delivered by mail.

Payment: 

Check to be sent with release form as registration fee (must be at least $100 non-refundable) *

Amount to be paid with credit card or drafted from checking acct through Paypal  (must be at least $100 non-refundable, or full family payment, whichever is less.)

$ This box cannot be left blank!

PayPal is a secure online service that allows you to pay with any major credit card, or have the amount drafted immediately from your checking acct.  Only a valid e-mail address is required.  This service will provide greater flexibility and security.  Makemie Woods does accept credit cards directly.

* If you are not using PayPal, include a check for this amount when mailing your release form!  Your camper will not be registered until payment is received.
  Note:  if you are entering a second child, make sure you re-calculate so that your discounts are factored properly

Balance due: (must be postmarked 3 weeks prior to starting date of camp session to avoid $25 late fee): 
$
If you have selected the Advance payment discount, this figure should be zero. If it is not, please check your figures and click the calculate button again.

If paying by the PayPal service, the figure above should match your PayPal total.

NO REFUNDS FOR DISCOUNTS NOT TAKEN ON THIS FORM.

If you have problems with this form, please contact mike@makwoods.org

Please print this form prior to submitting it for your own records.

modified 1/28/07 for makwoods.org