Camper Application

Camp Registration
Ages 8-12

$150.00

For information on camperships, contact us.
Camper Information
Name

First NameLast Name
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Birth Date

MonthDayYear
Date
Gender

MaleFemale
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
What is your relationship to the camper? (Parent, Grandparent, Aunt/Uncle, etc)
Emergency Contacts

Please provide 2 emergency contacts below
Emergency Contact #1

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency Contact #2

First NameLast Name
Phone Number
Please enter a valid phone number.
Authorized Pick-Up

Please list person authorized to pick up your child if other than Parent/Guardian above
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Camper Health
Medications & Special Instructions
I am allergic to...

No known allergiesFoodMedicineEnvironment (insect; stings; hay fever, etc.)Other
Please describe below what you are allergic to and the reaction seen
Are there any dietary restrictions we should be aware of?
Other Restrictions

I have reviewed the program and activities of the camp and feel that I can participate without restrictionsI have reviewed the program and activities of the camp and feel that I can participate with the following restrictions or adaptations.
Please describe restrictions below
Has/Does the camper:
Have recurrent/chronic illnesses

YesNo
Had a recent infectious disease

YesNo
Had a recent injury

YesNo
Had asthma/wheezing/shortness of breath

YesNo
Have Diabetes

YesNo
Had Seizures

YesNo
Had Headaches

YesNo
Had Fainting or Dizziness

YesNo
Passed out/had chest pain during exercise

YesNo
Had Mononucleosis-mono during the past 12 months

YesNo
If female, have problems with periods/menstruation

YesNo
Ever had back/joint problems

YesNo
Have problems with diarrhea/constipation

YesNo
Have any skin problems

YesNo
If answered yes to any of the above questions, please explain.
For travel outside the country, please name countries visited and dates of travel.
Mental, Emotional, and Social Health: Check "Yes" or "No" for Each Statement
Has the camper:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)

YesNo
Ever been treated for emotional or behavioral difficulties or an eating disorder

YesNo
During the past 12 months, seen a professional to address mental/emotional health concerns

YesNo
Had significant life events that continues to affect the camper's life (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)

YesNo
Please explain "Yes" answers in the space below, noting the number of the questions. The camp may contact you for additional information.
Health Care Providers
Name of primary physician(s)
Physician Phone Number
Please enter a valid phone number.
What Have We Forgotten to Ask?
Please provide in the space below any additional information about the camper's health that you think important or that may affect camper's ability to fully participate in the camp program.
Permission to Treat Authorization
I hereby give permission to the medical personnel selected by this Camp's director to provide routine health care; to administer prescribed medications; and to administer emergency treatment for my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

If the person named herein is a minor, it is my intention that representatives of the camp be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; and if the person named herein is a minor, to provide information to the camp representatives to keep me informed of my child's health situation.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the named person. This completed form may be photocopied for trips out of camp.
Camper Agreement
Indicate your agreement by clicking the box below

I AgreeI Do Not Agree
Parent/Guardian Signature (Required)

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Online Legal Guardian Waiver

The information collected below is for the camper/child listed above
Parental Notification Policy

Since all treatments of campers shall be recorded, a record of all emergency and first aid treatment by camp staff and volunteers shall be filed in the Priest Lake Kids Camp health and medical files. After the initial examination, the parent or legal guardian shall be notified if conditions warrant it, and if the camper is sent to see the Camp Physician or to an emergency department, the Activity Disclosure and Release for Participation in the Priest Lake Kids Camp Program is in full effect.

Priest Lake Kids Camp has done everything reasonable to assure that our camp programs have been made as safe as possible. However, we wish to inform you that camp activities are not without risk. As in any camp activity, such as challenge course, zipline, rock climbing, horsemanship, or water sports including swimming, canoeing, paddle boarding, wakeboarding, water skiing, or tubing, inherent risks exist and may result in serious injury or death. Should you not want your camper to participate in any of these specific activities, please list them in writing and submit it to us via email. Phone calls are not acceptable for exclusion. If you have any questions, please call 208-597-2726.

Emergency Treatment Authorization

In case of emergency, I hereby give permission to the physician(s) selected by the camp directors to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. As parent or legal guardian of the applicant, I am in favor of him/her attending camp, and accept the conditions named. The health history and application information are correct, as far as I know, and the person herein described has permission to engage in all prescribed camp activities, except as noted. In addition, I have read and understand this EMERGENCY TREATMENT AUTHORIZATION statement and give my full consent to the terms found therein. (This form may be photocopied for use out of camp.)

Contract of Release & Assumption of Risk Agreement

By signing below, I acknowledge I have read the above two statements and consent to their conditions. I realize camp activities have inherent risks. I knowingly accept and assume this risk, and agree to release Priest Lake Kids Camp, its employees, and any sponsoring organizations from liability in case of accident or illness. Priest Lake Kids Camp is not responsible for lost or damaged personal items, including cameras and personal recreational equipment, etc. (If personal recreation equipment is brought, it can only be used according to Priest Lake Kids Camp procedures and protocol by the owner.) I also agree that photographs and video of the applicant may be used for camp promotional material. I agree to abide by ALL camp regulations and policies and to uphold its objectives.
Completion Acknowledgement
Yes, I agree to terms of this agreement

Yes, I agree to terms of this agreement
Signature Required
Signature

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Camp Registration

Camper Information

Parent/Guardian Information

Emergency Contacts

Authorized Pick-Up

Camper Health

Has/Does the camper:

Mental, Emotional, and Social Health: Check "Yes" or "No" for Each Statement

Has the camper:

Health Care Providers

What Have We Forgotten to Ask?

Permission to Treat Authorization

Camper Agreement

Online Legal Guardian Waiver

Completion Acknowledgement

Signature Required