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Emergency Contact Information This person will be contacted if the Parent or Guardian is unavailable. Other than the 2 guardians listed above, and the

emergency contact, please list other adults who may pick up this camper in the Release of Minors area below.

Name _______________________________ Relationship to Camper _________________ Phone ___________________

2019 Registration Form

Relationship to Camper ______________________

Title _______

First Name ________________________________

Last Name ________________________________

Email ____________________________________

Cell Phone _____________________

Work Phone ___________________

Home Phone ___________________

Relationship to Camper ______________________

Title _______

First Name ________________________________

Last Name ________________________________

Email ____________________________________

Cell Phone _____________________

Work Phone ___________________

Home Phone ___________________

Please include a $50 NONREFUNDABLE DEPOSIT for each

camp.

Please complete a separate form for each camper.

Please Print Legibly

Parent/Guardian Information

Camper Information

For Office Use Only

First Name ___________________________________ Last Name ___________________________________

Gender: Male Female Date of Birth____/____/______ Age: _____ Grade in September 2019:______

Home Address_________________________________ City ______________________ State_____ Zip code __________

T-Shirt Size:

Youth/Child: Small Medium Large X-Large

Adult: Small Medium Large X-Large

Release of Minors All Campers are released at the end of camp to their parent/guardian (listed above),

emergency contact or one of the individuals below. NO EXCEPTIONS. Please be advised that photo identification and camper pickup ID card must be provided at time of pickup.

Name _______________________________ Relationship to Camper _________________ Phone ___________________

Name _______________________________ Relation ship to Camper _________________ Phone ___________________

Name _______________________________ Relation ship to Camper _________________ Phone ___________________

Parent/Guardian Signature _________________________________________________ Date___________________

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2019 Registration Form

Additional Information

Cabin Buddy* – for overnight Camps ONLY

*This is a REQUEST and not a guarantee

1st Choice _______________________________________ 2nd Choice _______________________________________

Housing Information- for overnight Camps ONLY

Cabin Covered Wagon (Wagons are not available for High School Camp)

DAY CAMPS- Ages 5-9 Regular Care– 8:30-3:30 Extended Care– 7:45-5:30 Spring Break Camp- March 25-29 Regular Care $155 Extended Care $175 Day Camp 1-July 8-12 Regular Care $235 Extended Care $265 Day Camp 2-August 5-9 Regular Care $235 Extended Care $265 Day Camp 3-August 26-30 Regular Care $235 Extended Care $265

OVERNIGHT CAMPS Grades 1-5 Elementary Overnight

EON– June19-21 $205

Grades 3-5 Junior Overnight

JR1– June 30-July 3 $219

JR2– August 18-22 $284

Grades 5-7 Tween Overnight

TW1– July 14-19 $354

TW2– August 11-16 $354

Grades 6-8 Middle School Overnight

MS1– June 23-28 $379

MS2– July 28-August 2 $379

Grades 9-12 High School Overnight

HS– July 21-26 $389

Camp Information Please select which camp(s) you would like to register for.

Parent /Custodial Issues

Check here if there are any unresolved legal parent/custodial issues that Camp Harlow needs to be aware of. NOTE: If you have a ‘working’ parenting plant, that does not necessarily constitute marking this box. Marking this box will initi-ate a request for more documentation. Please call the Camp Harlow office with any questions 541.683.5416.

If you marked YES, please explain:_____________________________________________________________________

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2019 Registration Form Additional Options

The Camp Store and Café are available for all ages and are an additional opportunity for campers to enjoy while they

attend Camp. The students attending our Tween, Middle School, and High School camps have the opportunity to add

paintball to their experience for an additional fee.

Camp Store & Cafe— Please select all that you desire

$10 $15 $20 $30 Donate the remaining Camp Store Balance to the Scholarship Program

Paintball— Please the number of Games you would like to play—(Eligible camps are Tween, Middle & High School)

1 Game $20

Media

Team or Cabin Photo $8

Camp Video, Online Delivery $15

Combo– Cabin Photo and Video $20

Help Sponsor another Camper— Please select the all that you desire

$5 $10 $25 Other $___________

Total (Including the camp and any options selected above) $________

Payment Information Minimum $50.00 deposit is required per camp. (This is NONREFUNDABLE and is a part of the total camp fee)

Total enclosed $____________

Payment method: Check Cash Visa MasterCard Other (AMEX/Discover)

Check Number ___________

Please Charge my credit Card:

Number ___________________________

Expiration Date ______/______

CVV ________

Billing Zip Code ___________

Print Name _______________________

Signature __________________________

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2019 Registration Form Camper Information

Does your Camper have any special interests/activities that he/she especially enjoys?

____________________________________________________________________________________________________

To help set your camper up for success, it here any additional information that would be pertinent for the counseling staff

to know about your camper? Please let us know below:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

How did you hear about Camp Harlow? ___________________________________________________________________

Medical Information

Does your camper have any known Allergies? Yes No

Please list below any known allergies and list treatment and details for them.

Allergies:

______________________________________________________________________________

______________________________________________________________________________

Details and Treatment:

______________________________________________________________________________

______________________________________________________________________________

Does your Camper have any Dietary Restrictions? Yes No

Please list below any known allergies and list treatment and details for them.

______________________________________________________________________________

______________________________________________________________________________

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2019 Registration Form Instructions for Medications at Camp Harlow

All Medication must be turned in to the nurse at registration. DO NOT pack any medication in your camper’s luggage.

All Medication must be in its ORIGINAL containers with the Camper’s name and instructions. (You may ask your phar-

macist for an extra container)

Please bring exact number doses plus one for time at camp. *No need to bring acetaminophen, ibuprofen or aspirin.

Sample medications will be accepted with a doctor’s note authorizing the medication with dosage and instructions.

All medication is kept in the Nurse’s station and is administered there.

Campers who need emergency inhalers or epi-pens may carry them. You may choose to leave these with the nurse. If

not, you must leave a backup supply at the Nurse’s station, one with camper, one with nurse.

Over the counter medications are not accepted. Please see the list on the following page of the over the counter medi-

cations that are on hand.

Camp Harlow must be made aware of any special needs or considerations at minimum of 2 weeks prior to the camp .

Medication Information

Name of Medication Dosage Time Reason for Medication

Please list any current medical conditions or concerns, any recent injury, or limitations to activities at Camp

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Over the Counter Medications Please mark any medications that you DO NOT want your child to have.

The Camp Harlow consulting physician has issued standing orders permitting the dispensing of common over the counter

medications. These will be dispensed as needed. DO NOT send these medications with your camper.

Also, please mark any medication that you DO NOT want your child to have.

2019 Registration Form Doctor and Insurance Information

This person will be contacted if the Parent/Guardian or Emergency Contact are not available

Family Doctor Name _____________________________________________________Phone Number ________________

Health Insurance Company _____________________________________________________________________________

Date of last Tetanus Shot _____/_____/_____ (A tetanus shot is required)

Non-aspirin pain reliever (Tylenol or generic)

Ibuprofen (Advil or Motrin)

Antacid (Mylanta or Tums)

Antihistamine (Bendadryl, Loratadine, Cetirizine)

Cough Syrup (Robitussin DM)

Decongestant (Sudafed PE)

Imodium (for Diarrhea)

Pepto Bismol

Melatonin

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Health History Information Please review the following list and note if they have any of the following

medical conditions and how they are treated.

2019 Registration Form

Conditions No Yes Un-

known Details

Asthma

Diabetes

Physical Needs or

Challenges

Developmental Delays

Behavioral Concerns

Emotional Concerns

Social Concerns, or con-

cerns with interactions

Needs Specific Redirection

Activity Restrictions

Special Assistance

Other Medical Challenges

Other Needs

Do you require our Medical staff to follow up with you? Yes No

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Parental Release

2019 Registration Form

AUTHORIZATION OF TREATMENT

I, the parent or legal guardian of the listed camper, hereby give permission to Camp Harlow to

administer medication as previously listed. I understand that it is my responsibility to provide pre-

scription medication in original pharmacy containers or as labeled physician samples.

I understand that if my camper requires medical attention in additional to the described above,

that Camp Harlow will attempt to contact me first. If I am unavailable, I authorize Camp Harlow to

contact my camper’s physician. If neither I nor my child’s physician. If neither I nor my child’s phy-

sician is available, I authorize Camp Harlow and First Baptist Church to order X-Rays, routine tests,

and treatments ; to release any records necessary for insurance purposes; and to provide or ar-

range transportation for my camper to a nearby clinic or hospital. I will hold harmless Camp Har-

low, its staff and the First Baptist Church of Eugene, and its pastors from any claim of liability aris-

ing from attending camp.

PHOTO/VIDEO RELEASE INFORMATION

During our camp sessions, the Camp Harlow Staff takes photo and videos for cabin or team pho-

tos, daily videos, slide shows and promotional purposes. If there are reasons that your child

should not be photographed or on video, please contact the Camp Harlow Office at 541.683.5416

at your earliest convenience.

ACTIVITIES & TRAVEL RELEASE

I, the parent or legal guardian of the previously listed camper, hereby give permission for my

camper to travel to and participate in offsite Camp Harlow Middle School or High School activities

such as Breakfast on the Butte, Service Projects, and Lake Day.

I, the parent or legal guardian of the previously listed camper, hereby give permission for my

camper to participate in onsite Camp Harlow activities such as; Zipline, Big Swing, Challenge

Course, Intensity Bridge, Flying Squirrel, Canoes, Fort Hawk, Inflatables, Rockwall, Archery, Swim-

ming Pool, Go Carts, Fire Truck Rides, and Train Rides.

I, the parent or legal guardian of the previously listed camper, hereby give permission for my

camper to ride and or be around horses at Camp Harlow.

________ INITIALS ________ INITIALS ________ INITIALS ________ INITIALS ________ INITIALS ________ INITIALS

Signature of Parent/Guardian __________________________________

Printed name of Parent/Guardian _______________________________ Date _____________

NOTE: by initialing and signing above, you acknowledge that you have read and agreed to each item.