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Registration


Youth Camp Registration
 
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You can either send a check to Camp Esquagama, 4913 Pine Lane, Gilbert, MN 55741 or you can charge by Visa/MasterCard at PayPal

Name
(Last, First, M.I.):
Age:
Sex: Female Male
Birth Date:
Parent or Guardian:
Address:
City:
State:
Zip:
County:
Phone:
*Email:
T-Shirt Size


Youth Camp Session Selection

Youth Camp 1
Session One (5 Days)
June 11 - June 15, 2012
Youth Camp 2
Session 2 (7 Days)
June 23 - 29, 2012
Youth Camp 3
Session Three (5 Days)
July 2 - 6, 2012
Youth Camp 4
Session Four (6 Days)
July 8 - 13, 2012
Youth Camp 5
Session Five (5 Days)
July 16-20, 2012
Youth Camp 6
Session Six (5 Days)
July 23-27, 2012
Youth Camp 7
Session Seven (6 Days)
July 29 - Aug 3, 2012
 

Day Camp Session Selection

Day Camp 1
June 11 - 15, 2012
Day Camp 2
June 18 - 22, 2012
Day Camp 3
June 25 - 29, 2012
Day Camp 4
July 2 - 6, 2012
Day Camp 5
July 9 - 13, 2012
Day Camp 6
July 16 - 20, 2012
Day Camp 7
July 23 - 27, 2012
Day Camp 8
July 30 - Aug 3, 2012
List one preferred cabin mate:

Refer a Friend

Refer and friend and receive $20 off your camp fee for each NEW camper. Your friend(s) must be registered by May 1, 2012 and they must be new to Camp Esquagama. Credit is non-refundable and nontransferable. Refer a friend promotion ends May 1, 2012. All referrals must be submitted along with registration form.

Referral Name:
Referral Address:
Referral Phone:
Referral Email:

Referral Name:
Referral Address:
Referral Phone:
Referral Email:

Health Information

Parent or Guardian Name:
Phone:
Address:
Health History (Check affirmative)
Health History
ear infections
heart disease/ defect
convulsions
fainting spells
headaches
bed-wetting
diabetes
bleeding/ clotting disorders
hypertension
kidney trouble
bronchitis
Diseases
mononucleosis
chicken pox
measles
German measles
mumps

Mental/Emotional Health (to help us better serve your child)
ADD/AD/HD
depression
learning disability
other emotional health concerns
Allergies
hay fever
ivy poisonings
insect stings
asthma
penicillin
other drugs
food
describe allergic responses
Operations or serious injuries (dates):
Chronic or recurring illness:
Present Medications:
Dietary Restrictions:
Specific activities restricted
(i.e. swimming, canoeing, water-skiing, etc.):
Medications & Allergy serums must be in pharmacy containers with doctors instructions.

Please notify the camp if this camper is exposed to any communicable disease during the three weeks prior to camp attendance. If health history reveals problems, then a physical exam by a physician within one year is required.

Immunization Record

DPT Series
Polio OPV Sabin
Tuberculin Test
DPT Booster
OPV Booster
MMR
Tetanus Booster

Parents' Authorization

My child has permission to participate in all camp programs. I understand that there might be risks and dangers connected with some of the activities that are conducted at Camp Esquagama, and I agree to release St. Louis County, the Camp, its directors, agents and all employees from any liability, legal actions or claims which I or my child have, or might have, for any damage or injury to the child as a result of being enrolled as a camper at Camp Esquagama or from participating in any activity that results in damage or injury to my child or loss or damage of personal property, whether caused by the negligence of St. Louis County, Camp Esquagama, its directors, agents and all employees. The agreement is deemed to be entered into in the State of Minnesota and to be governed and enforced pursuant to Minnesota law. I agree that this agreement will be governed and construed in accordance with the laws of the State of Minnesota. I submit to the exclusive jurisdiction of any court of the State of Minnesota located in the County of St. Louis for the purpose of any suit, action or other proceeding, including those for personal injuries, arising from or related to St. Louis County, Camp Esquagama or this agreement. I agree that in any event that I take any legal action against St. Louis County or Camp Esquagama, which is decided in favor of either St. Louis County or Camp Esquagama, I will be responsible for all legal fees, court costs and out-of-pocket expenses of St. Louis County, Camp Esquagama and their employees.

In signing this application, the parent agrees that the camper must conform to the rules and regulations of Camp Esquagama and agrees to cooperate with the staff in the best interests of Camp Esquagama and its campers. I understand that pictures of camp activities are taken routinely, and I give my permission to Camp Esquagama to use these pictures for promotional purposes. This application has my consent and approval. I further understand that the camp will not carry special health and accident insurance on my child. Below I have indicated my insurance company's name and my policy number. Authority is granted without limitation to Camp Esquagama, its owners, directors, employees and agents in all medical matters to hospitalize, treat, and order injection, anesthesia, and surgery for the camper. The parent is responsible for advising/providing to Camp Esquagama, its owners, directors, employees and agents all pre-existing medical conditions of the camper, out-of-camp medical, surgical, hospital, pharmaceutical, allergy expenses and for providing adequate quantities of necessary medications to Camp Esquagama in pharmacy containers with doctor's instructions.


Insurance Company
Policy Number
Parent or guardian's Electronic Signature
Date


   
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