Home › Youth Recharge Camper ApplicationYouth Recharge Camper Application Parent/Guardian Name*FirstLast Relationship to Camper(s)*Select RelationshipMotherFatherStep-MotherStep-FatherGrandparentGuardian How many campers are applying at this time? 1234 Address* Street Address City State Zip Code Phone* Alternate Phone* Email* Home Congregation Emergency Contact Name*FirstLast Emergency Contact Relationship to Camper(s)*Select RelationshipMotherFatherStep-MotherStep-FatherGrandparentAunt/UncleOther FamilyFriend of the Family Emergency Contact Phone Emergency Contact Alternate Phone*Camper 1 Information Camper 1 Name*FirstLast Camper 1 Birthdate* Camper 1 Gender*Select GenderMaleFemale Camper 1 T-shirt Size*Select SizeYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large Camper 1 Boys Cabin Request - Select another camper you would like to be with in your cabin.SelectAnother Camper Camper 1 Girls Cabin Request - Select another camper you would like to be with in your cabin.SelectAnother Camper Camper Name* Camper 1 Phone Camper 1 Email Camper 1 - Can the camper swim?*SelectYesNo**Send flotation device with camper** Camper 1 Date of Last Tetanus Shot* Camper 1 Primary Physician* Camper 1 Primary Physician Phone* Camper 1 - Do you give permission to administer the medications listed below?YesNoTylenolIbuprofenBenadrylTumsHydrocortisone Camper 1 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*SelectYesNo 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.Heart DiseaseConvulsionsDiabetesAsthmaEar InfectionBed WettingHyperactiveOther 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.)SwimmingPhysical ExerciseOther Camper 1 - Other Activity Exception(s)*Camper 2 Information Camper 2 Name*FirstLast Camper 2 Birthdate* Camper 2 Gender*Select GenderMaleFemale Camper 2 T-shirt Size*Select SizeYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large Camper 2 Boys Cabin RequestSelectAnother Camper Camper 2 Girls Cabin RequestSelectAnother Camper Camper Name * Camper 2 Phone Camper 2 Email Camper 2 - Can the camper swim?*SelectYesNo**Send flotation device with camper** Camper 2 Date of Last Tetanus Shot* Camper 2 Primary Physician Same as Camper 1?SelectYesNo Camper 2 Primary Physician* Camper 2 Primary Physician Phone* Camper 2 - Do you give permission to administer the medications listed below?YesNoTylenolIbuprofenBenadrylTumsHydrocortisone Camper 2 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*SelectYesNo 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.Heart DiseaseConvulsionsDiabetesAsthmaEar InfectionBed WettingHyperactiveOther 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.)SwimmingPhysical ExerciseOther Camper 2 - Other Activity Exception(s)*Camper 3 Information Camper 3 Name*FirstLast Camper 3 Birthdate* Camper 3 Gender*Select GenderMaleFemale Camper 3 T-shirt Size*Select SizeYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large Camper 3 Boys Cabin RequestSelectAnother Camper Camper 3 Girls Cabin RequestSelectAnother Camper Camper Name * Camper 3 Phone Camper 3 Email Camper 3 - Can the camper swim?*SelectYesNo**Send flotation device with camper** Camper 3 Date of Last Tetanus Shot* Camper 3 Primary Physician Same as Camper 1?SelectYesNo Camper 3 Primary Physician* Camper 3 Primary Physician Phone* Camper 3 - Do you give permission to administer the medications listed below?YesNoTylenolIbuprofenBenadrylTumsHydrocortisone Camper 3 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*SelectYesNo 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.Heart DiseaseConvulsionsDiabetesAsthmaEar InfectionBed WettingHyperactiveOther 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.)SwimmingPhysical ExerciseOther Camper 3 - Other Activity Exception(s)*Camper 4 Information Camper 4 Name*FirstLast Camper 4 Birthdate* Camper 4 Gender*Select GenderMaleFemale Camper 4 T-shirt Size*Select SizeYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large Camper 4 Boys Cabin RequestSelectAnother Camper Camper 4 Girls Cabin RequestSelectAnother Camper Camper Name * Camper 4 Phone Camper 4 Email Camper 4 - Can the camper swim?*SelectYesNo**Send flotation device with camper** Camper 4 Date of Last Tetanus Shot* Camper 4 Primary Physician Same as Camper 1?SelectYesNo Camper 4 Primary Physician* Camper 4 Primary Physician Phone* Camper 4 - Do you give permission to administer the medications listed below?YesNoTylenolIbuprofenBenadrylTumsHydrocortisone Camper 4 - Any known Allergies, Current Medications, Physical Conditions, or Activity Exceptions?*SelectYesNo 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.Heart DiseaseConvulsionsDiabetesAsthmaEar InfectionBed WettingHyperactiveOther 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.)SwimmingPhysical ExerciseOther 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.SelectYesNo I have read and understand the Camp Rules, Dress Code, and Cabin Assignments.*SelectYes 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.*SelectYes I verify that all the information provided in this application is true and accurate to the best of my knowledge. *SelectYesThe 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 Select Payment MethodSelectPay Online NowPay with Cash or CheckMake checks payable to: Venice Church of ChristMemo: Youth RechargeMail to, before July 24: 1806 Governor AveNorth Port, FL 34288Campers = $40.00 each Number of Campers*Select Number of Campers1 Camper2 Campers3 Campers4 Campers Total Online Payment stripeUpon clicking Submit your application and payment will be processed and a confirmation email will be sent to the Parent/Guardian email address provided.SubmitReset
