LaVerne Griffin Camp Registration & Health Form

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A form will need to be filled out for each camper. Siblings CANNOT be combined on one form. Thank you for understanding.

Email *

Camper's Name (First and Last): *

Birthday of Camper (Month/Day/Year): *

What grade will your child be entering in fall 2021?

Sex: *

Female

Male

Camp Attending: *

Trailblazer Camp June 7-11 *Co-ed Alaska Native Camp for those entering 7th-12th grade*

Pathfinder Camp June 13-17 *Co-ed Youth Camp for those entering 7th-12th grade*

Pioneer Camp June 20-24 *Co-ed Kids Camp for those entering 2nd-6th grade*

*NEW* Campfire Day Camp June 28-30 10a-3p *Co-ed kids camp for those entering K & 1st grade*

Parent/Guardian Name: *

Parent/Guardian Phone (home, cell, work): *

Parent/Guardian Address: *

Two Emergency Contacts (Name, Relationship to Camper, and Phone Number) *

Insurance Information for your camper is required. Please list the Carrier, policy holder name, ID #, Group #, Address of Insurance, and Phone # of insurance. *

Primary Care Doctor and Phone Number: *

Are Immunizations up to date? *

Yes

Other:

Medication, diet, or any medical conditions the Camp Nurse should be aware of? *

Please list any allergies and reactions (If none, please type NONE): *

Essential Medical Information: All medications must be in the original prescription bottles with detailed instructions from a doctor. For the safety of everyone in camp and to comply with regulations, all medication will be stored in our nurse's office. The following over the counter medications are kept in the nurse's office & are provided to campers by our Camp Nurse. These would include: Acetaminophen, Ibuprofen, Tums, Mylanta, and Benadryl. LaVerne Griffin Camp does not provide specialized diets. The Camp Nurse is available the day of check-in for any questions or concerns. *

Agree

Disagree

Other

Parent's Authorization (ALL boxes must be selected to continue with camp registration) : *

I certify that this health history is correct to the best of my knowledge.

I understand the possible risk and dangers involved in sports and other traditional camp activities and DO give my permission for the above named camper to engage in all camp activities, except noted by myself or my primary physician. I release LaVerne Griffin Camp, it's employees, agents, and camp staff from all claims, demands, actions, or causes of action for any sort of injuries sustained during the period covered by this release whether such injury occurs on or off camp property.

I give permission for medical treatment to be initiated as required for his/her welfare.

Required

I give LaVerne Griffin Camp permission to use photographic images or videos of the above participant for the purpose of promoting the camp's programs in publications, social media, and on the web. I agree that the images become exclusive property of LaVerne Griffin Camp and wave the rights. For privacy and protection of your child/ward, his or her name will not be used.

Yes

Other:

Clear selection

Printed Name of Parent/Guardian(***You will be asked to sign your application the first day of camp at check-in***): *

Date: *

YYYY

A $25 non-refundable deposit is due at registration in order to reserve your campers spot. You can also pay the entire amount via check or you can checkout on our website. If you'd like to pay on our website, click the link below BEFORE SUBMITTING THIS FORM. ***(Note: this will bring up a separate window to send payment. You will still need to complete this form and click "SUBMIT" at the bottom.)*** *

Mail check to: LaVerne Griffin Camp PO Box 299069 Wasilla, AK 99629

Checkout at https://www.lavernegriffincamp.org/camp-payment

A copy of your responses will be emailed to the address you provided.

Submit

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