Music Camper Registration & Health History

Insurance Information

Parents and guardians are responsible for medical expenses incurred for illness or injury at Choir Camp. Insurance Co/Medicaid:

Name of Insurance Company:

Policyholder's Name:

Insurance ID Number:

Insurance Group Number:

If no insurance, responsible party:

Please list any allergy:

List over-the-counter medications the camper cannot receive for minor symptoms.

Operations/Serious Injuries & Dates:

Chronic or Recurring Illnesses:

Medications

Please list medications that will be given to camp nurse on check-in, including drug, dosage and condition requiring the medication. Prescribed medication and inhalers MUST be in original container with pharmacy label that includes camper’s name, valid date, instructions and Dr’s name. Sample medications MUST have signed physician’s letter. Over-the-counter medications MUST be in original packaging with valid expiration date.

Drug/Dosage/Condition

Name of church:*(Required)

Camper’s musical ability will be assessed on arrival at camp. Please describe camper’s past musical experiences or lessons, choir or band:

No previous musical or choral experience is required for attendance.

Is the camper part of a choir, band or orchestra?

What are your camper’s interests, hobbies, and activities?

Describe your camper’s personality:

Please include limitations, characteristics, or behavioral issues which could help the staff in working (sunburn sensitivity, sleepwalking, bedwetting, etc.)

Please rate your camper in the following areas:
4 = Excellent
3 = Good
2 = Needs Improvement
1 = No experience

Ability to live cooperatively in a community setting for a period of six days:

Ability to independently take care of their own personal needs (i.e. showering, personal hygiene, dressing, etc.)

Ability to stay away from home for an extended period of time:

Roomate Preference

Roommate requests will be honored as much as possible, but no requests are guaranteed. Rooms are double-occupancy, two room suites with showers.

Music Camper Registration & Health History

Camper Personal Information

Parent Contact Information

Non-Parent Emergency Contact

Insurance Information

Allergies & Illness

Medications

Camper Information

Roomate Preference

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