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Registration for Ithiel Falls Teen Camp
July 22 - August 2, 2015
Camper Information:
Name of Applicant ____________________________________________________________M________ F________
(Applicants must be twelve or entering 7th grade)
Address_____________________________________________________________________________________________
Mailing Address: City, State, Zip Code ____________________________________________________________
Telephone _____________________ E-mail address _______________________Birthdate _____/_____/_____
In Case of Emergency, Contact:
Name _______________________________________ Relationship ______________________
Telephone _____________________________ (Home) __________________________(Work)
List any allergies that could affect/hinder camp life:
______________________________________________________________________________
List Medications and dosage:
______________________________________________________________________________
Date of last tetanus shot:___________________________
Insurance Information:
PLEASE NOTE: Campers must provide their own insurance.
My child, _________________________________, has my permission to take part in all camp
activities. I understand that I must use my own medical insurances to cover his/her medical
expenses.
Name of Insurance________________________________Policy Number__________________
Signed______________________________________________________ __________________
Parent or Guardian
Date
“I understand that Ithiel Falls Camp Meeting does not provide any accident or medical
insurance for my child. I understand that I am required to provide accident/medical insurance
for my child and do so under the policy listed above. I agree that I am financially responsible for
any and all medical expenses associated with my child’s participation in this program.
(NOTE: Your child will not be allowed to participate in our camps unless your medical insurance
provider and policy number is provided below.) I agree, on behalf of myself, my child, and our
assigns, executors, and heirs, to indemnify, and hold harmless, Ithiel Falls Camp Meeting, and
its trustees, officers, agents and employees from any and all liability, damage and claims of any
nature arising out of or in any way related to my child’s participation in this program.”
_______________________________________ ______________________________________
Parent or Guardian (please print)
Signature of Parent or Guardian
Emergency Medical Authorization
In case of emergency, I ________________________________, hereby give my permission to
the physician selected by the camp staff to secure the proper treatment for my child,
__________________________, including hospitalization, any injection, anesthesia, or surgery.
(PLEASE NOTE: EVERY EFFORT WILL BE MADE TO CONTACT THE PARENT IN CASE OF AN
EMERGENCY.)
Signed ___________________________________________________ _________________
Parent or Guardian
Date
Make sure you fill out the attached Medical Form. Your camper will NOT be allowed to stay
without it filled out and SIGNED by your Doctor with all Medications listed on it.
COST OF CAMP: $175.00
This fee includes ALL activities. There will be a multi-sibling discounted fee of $165 per student
and only applies to early registrants.
The registration fee is $215.00 if registration is not received or postmarked by July 8th.
REGISTER EARLY!!! Space is limited to the first 40 girls and 40 boys who apply, so send this
completed registration form (one for each camper) with $25.00 (nonrefundable, will be applied
to the total fee) to:
Ithiel Falls Camp Meeting, P.O. Box 316, Johnson, VT 05656
Enclosed $________
Campers should sign in at the Camp Ground between 2:30 and 4:30 p.m. on Wednesday, July
22th, 2015 and plan to stay until check-out between 3:30 and 4:30 pm on Sunday, August 2th,
2015. Campers may not arrive before July 22th, 2015.
Church camper attends: _________________________________
Signature of Pastor: ____________________________________
Ithiel Falls Teen Camp Medication and Prescription Drug Form
Campers will not be allowed to attend or be given any medication at camp if this form is not
completely filled out with a Doctor’s Signature.
Camper Name ____________________________________________ D.O.B.________________
Non-Prescription Medication Permission**:
I grant permission for the camp to dispense the following non-prescription medications:
_______ Tylenol _______ Advil _______ Tums _______ Benadryl _______ Hydrocortisone
_______ Poison Ivy Ointment _______ Other _____________________ to student as necessary.
** NO medication will be given without signed permission and/or that is not in the original packaging.
Parent/Guardian Signature: _____________________________ Date: _________
Prescription Medication Permission (Such as EpiPen, Inhaler, etc.):
Medication 1___________________ Dosage __________Directions_________________
Reason Medicine is Needed _________________________________________________
________________________________________________________________________
Medication 2___________________ Dosage __________Directions_________________
Reason Medicine is Needed _________________________________________________
________________________________________________________________________
Medication 3___________________ Dosage __________Directions_________________
Reason Medicine is Needed _________________________________________________
________________________________________________________________________
Medication 4___________________ Dosage __________Directions_________________
Reason Medicine is Needed _________________________________________________
________________________________________________________________________
Physician’s Signature ________________________________ Date ____________
(Must be signed by Physician before camp)
NO medication will be given at Ithiel Falls until the Camp receives this completed form with
the prescribed medication in a container appropriately labeled by the physician or pharmacy.
Parent Authorization:
I, _______________________________, hereby give my permission for my child,
_________________________________, to take the above medications at Ithiel Falls Camp
Meeting as ordered above.
Parent/Guardian Signature:___________________________________ Date: ______________