Pinellas Park Summer Camper Application

Parent/Guardian Name*

First

Last

Relationship to Camper(s)*

How many campers are applying at this time?

Address*

Street Address City State Zip Code

Phone*

Alternate Phone*

Email*

Home Congregation

Emergency Contact Name*

First

Last

Emergency Contact Relationship to Camper(s)*

Emergency Contact Phone*

Emergency Contact Alternate Phone

Camper 1 Information

Camper 1 Name*

First

Last

Camper 1 Birthdate*

Camper 1 Gender*

Camper 1 T-shirt Size*

Camper 1 Boys Cabin Request - Select another camper you would like to be with in your cabin.

Camper 1 Girls Cabin Request - Select another camper you would like to be with in your cabin.

Camper Name*

Camper 1 Phone

Camper 1 Email

Camper 1 - Can the camper swim?*

**Send flotation device with camper**

Camper 1 Date of Last Tetanus Shot*

Camper 1 Primary Physician*

Camper 1 Primary Physician Phone*

Camper 1 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*

Camper 1 - Check any physical conditions below which the camp director or nurse should know. Reporting such conditions will not prevent the child from attending camp and will be kept in confidence by the staff.

Camper 1 - Other Physical Condition*

Camper 1 - Any Known Allergies, What is the reaction and what treatment is necessary i.e. Epi Pen, Benadryl?

Camper 1 - Any Current Medications, include frequency and dose details

Camper 1 - This camper has my permission to attend camp and participate in all activities EXCEPT the following: (Check those activities in which the child should NOT participate in.)

Swimming

Physical Exercise

Other

Camper 1 - Other Activity Exception(s)*

Camper 2 Information

Camper 2 Name*

First

Last

Camper 2 Birthdate*

Camper 2 Gender*

Camper 2 T-shirt Size*

Camper 2 Boys Cabin Request

Camper 2 Girls Cabin Request

Camper Name *

Camper 2 Phone

Camper 2 Email

Camper 2 - Can the camper swim?*

**Send flotation device with camper**

Camper 2 Date of Last Tetanus Shot*

Camper 2 Primary Physician Same as Camper 1?

Camper 2 Primary Physician*

Camper 2 Primary Physician Phone*

Camper 2 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*

Camper 2 - Check any physical conditions below which the camp director or nurse should know. Reporting such conditions will not prevent the child from attending camp and will be kept in confidence by the staff.

Camper 2 - Other Physical Condition*

Camper 2 - Any Known Allergies, What is the reaction and what treatment is necessary i.e. Epi Pen, Benadryl?

Camper 2 - Any Current Medications, include frequency and dose details

Camper 2 - This camper has my permission to attend camp and participate in all activities EXCEPT the following: (Check those activities in which the child should NOT participate in.)

Swimming

Physical Exercise

Other

Camper 2 - Other Activity Exception(s)*

Camper 3 Information

Camper 3 Name*

First

Last

Camper 3 Birthdate*

Camper 3 Gender*

Camper 3 T-shirt Size*

Camper 3 Boys Cabin Request

Camper 3 Girls Cabin Request

Camper Name *

Camper 3 Phone

Camper 3 Email

Camper 3 - Can the camper swim?*

**Send flotation device with camper**

Camper 3 Date of Last Tetanus Shot*

Camper 3 Primary Physician Same as Camper 1?

Camper 3 Primary Physician*

Camper 3 Primary Physician Phone*

Camper 3 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*

Camper 3 - Check any physical conditions below which the camp director or nurse should know. Reporting such conditions will not prevent the child from attending camp and will be kept in confidence by the staff.

Camper 3 - Other Physical Condition*

Camper 3 - Any Known Allergies, What is the reaction and what treatment is necessary i.e. Epi Pen, Benadryl?

Camper 3 - Any Current Medications, include frequency and dose details

Camper 3 - This camper has my permission to attend camp and participate in all activities EXCEPT the following: (Check those activities in which the child should NOT participate in.)

Swimming

Physical Exercise

Other

Camper 3 - Other Activity Exception(s)*

Camper 4 Information

Camper 4 Name*

First

Last

Camper 4 Birthdate*

Camper 4 Gender*

Camper 4 T-shirt Size*

Camper 4 Boys Cabin Request

Camper 4 Girls Cabin Request

Camper Name *

Camper 4 Phone

Camper 4 Email

Camper 4 - Can the camper swim?*

**Send flotation device with camper**

Camper 4 Date of Last Tetanus Shot*

Camper 4 Primary Physician Same as Camper 1?

Camper 4 Primary Physician*

Camper 4 Primary Physician Phone*

Camper 4 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*

Camper 4 - Check any physical conditions below which the camp director or nurse should know. Reporting such conditions will not prevent the child from attending camp and will be kept in confidence by the staff.

Camper 4 - Other Physical Condition*

Camper 4 - Any Known Allergies, What is the reaction and what treatment is necessary i.e. Epi Pen, Benadryl?

Camper 4 - Any Current Medications, include frequency and dose details

Camper 4 - This camper has my permission to attend camp and participate in all activities EXCEPT the following: (Check those activities in which the child should NOT participate in.)

Swimming

Physical Exercise

Other

Camper 4 - Other Activity Exception(s)*

Agreements and Signature

I agree that Weeki Wachee Christian Camp may use photographs or video of the camper with or without the campers name and for any lawful purpose.

I have read and understand the Camp Rules, Dress Code, and Cabin Assignments.*

I understand responsible adults act as lifeguards during swim time, but may not have an active lifeguard certificate. I understand that first aid will be available and administered if necessary at the camp and that if serious injury or illness develops, medical and/or hospital care will be given. I further understand that in case of serious injury or illness I will be notified; but if it is impossible to contact me, I give my permission for emergency treatment and/or surgery as recommended by the attending physician. (Included in the camp fee is a group insurance policy covering accidental injury to campers at camp above family insurance). The camp and/or staff, however, will not be held responsible in case of illness or accidental injury.*

I verify that all the information provided in this application is true and accurate to the best of my knowledge. *

The electronic signature below and its related fields are treated by Weeki Wachee Christian Camp like a physical handwritten signature on a paper form.

Electronic Signature*

Date*

Payment

How many campers are applying at this time?*

Total Online Payment

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Upon clicking Submit your application and payment will be processed and a confirmation email will be sent to the Parent/Guardian email address provided.