Saint Sophia Camp - Camper Winter Registration

Winter 2019 Camper Registration

Saint Sophia Winter Camp at Thousand Pines Camp

359 Thousand Pines Road, Crestline, CA 92325
thousandpines.com

Sunday, December 29 - Wednesday, January 1, 2020

* Denotes required information. Incomplete forms cannot be processed.

Application for camper registration. One application per camper.

Camper Information

* Last name:

* First name:

Middle:

* Home Phone:

* Address:

* City:
* State: * Zip Code:

* Sex:
Male Female

* Date of Birth:

* Age: * Age at Camp:

* Home Parish:

Other Home Parish (include parish name, city and state):

* Father:

Father's Business Phone:

Father's Cell Phone:

* Mother:

Mother's Business Phone:

Mother's Cell Phone:

* Camper's E-mail: Confirmation receipt will be e-mailed to both Camper and Parents.

* Parents E-mail: Confirmation receipt will be e-mailed to both Camper and Parents.

* Camp Dates

Sunday, December 29 - Wednesday, January 1, 2020:

Camper Fees

$350 per child.

Convenience fee of $10.00 for optional credit card payment. $10.00 will be included automatically for online payments. Please note: Credit cards will not be processed immediately.

Otherwise, checks must be received 5 days after registering.

You must provide your own transportation to and from camp.

No transportation will be provided.

Notes

Please do not say "none" or "n/a" if there are no comments.
If you are typing a list, please use commas instead of a "dash" or "hyphen". — Thank you!

Any special comments:

Consent Section

I hereby give my consent to have my child attend the camp sponsored by Saint Sophia Cathedral.

* Parents Signature:
Check this box to verify the parents signature.

* Date:

I have read the Camper Information sheet for winter camp and agree to adhere to the Policies and Procedures. (Launches in new tab / window.)

* Parents Signature:
Check this box to verify the parents signature.

* Date:

* Camper Signature:
Check this box to verify the camper signature.

* Date:

Emergency Contact Information

* Emergency contact name:

* Home address:

* City:
* State: * Zip Code:
* Emergency home phone:

Emergency cell phone:

Health History

Frequent ear infections:
Yes No
Approximate date:

Heart Defect/Disease:
Yes No
Approximate date:

Convulsions:
Yes No
Approximate date:

Diabetes:
Yes No
Approximate date:

Bleeding/Clotting Disorders:
Yes No
Approximate date:

Hypertension:
Yes No
Approximate date:

Psychiatric Treatment:
Yes No
Approximate date:

Mononucleosis:
Yes No
Approximate date:

Diseases
Chicken Pox:
Yes No
Approximate date:

Measles:
Yes No
Approximate date:

German Measles:
Yes No
Approximate date:

Mumps:
Yes No
Approximate date:

Allergies
Hay Fever:
Yes No
Approximate date:

Ivy Poisoning, etcetera:
Yes No
Approximate date:
Insect Stings:
Yes No
Approximate date:

Asthma:
Yes No
Approximate date:

Penicillin:
Yes No
Approximate date:

Please do not say "none" or "n/a" if there are no comments.
If you are typing a list, please use commas instead of a "dash" or "hyphen". — Thank you!

Other Drug Allergies:

Approximate date:

Has this camper ever required any hospitalization or psychiatric counseling?

Operations or serious injuries (please include dates):

Disability or chronic or recurring illness:

Please do not say "none" or "n/a" if there are no comments.
If you are typing a list, please use commas instead of a "dash" or "hyphen". — Thank you!

Fainting:

Any Allergies (food, drugs, plants & insects):

Any medical prescribed meal plan or dietary restrictions:

Lactose intolerant:
Yes No

Any specific activities to be encouraged or limited by physician's advice:

Current Medication(s) (send with instructions):

Last Date of tetanus vaccination:

Wears Contacts:
Yes No

Please do not say "none" or "n/a" if there are no comments.
If you are typing a list, please use commas instead of a "dash" or "hyphen". — Thank you!

Other special considerations?

For Female
Has this person menstruated?
Yes No

If not, has she been told about it?
Yes No

If so, is her menstrual history normal?
Yes No

Special menstrual considerations:

Name of dentist/orthodontist:

Dentist Phone:

Name of family physician:

Physician Phone:

Presently under the care of a physician?
Yes No

Date of last physical exam:

Medical Insurance Information

Do you carry family medical insurance?
Yes No

Medical Insurance Company:

i.e. Anthem Blue Cross, Blue Shield, Health Net, Kaiser, etcetera.

Policy or group number:

Social Security number in case of hospital admission (no spaces or dashes):

Important - This section MUST be completed for Attendance

We, the parent(s) or legal guardian hereby authorize and give consent to any x-ray examination, or surgical diagnosis rendered under the general or special supervision of a licensed personnel on the staff of any licensed hospital. This authorization is given to provide authority and power to render care, which is deemed advisable in the best judgment of the physician. It is understood that an effort will be made to contact the undersigned prior to rendering treatment, but that any of the above treatment will not be withheld if the undersigned cannot be reached.

In recognition of the possible dangers to my child, I hereby knowingly and voluntarily waive any right or cause of action of any kind against the members, directors, agents, employees of the Greek Orthodox Archdiocese of America, the Greek Orthodox Metropolis of San Francisco, Saint Sophia Cathedral, Saint Sophia Camp, my local parish, and camp staff for any personal injury to my child occurring during the transportation of campers and staff to and from Camp Seely.

I hereby understand the Greek Orthodox Archdiocese of America has limited medical insurance. Any medical expenses that my child may incur due to personal injury or illness is my financial responsibility and not that of the Greek Orthodox Archdiocese of America, the Metropolis of San Francisco or the directors, Saint Sophia Cathedral, Saint Sophia Camp, agents, employees, camp staff and members of these organizations.

* Parent / Guardian Signature:
Check this box to verify the parents signature.

* Please print name:

* Date:

Immunization History

Vaccines	Year of Basic Immunization	Year of Last Booster
Diptheria
Pertussis (Whooping Cough):
Tetanus:
or
Tetanus:
Diptheria:
or
Tetanus:
Oral Polio (Sabin):
Injectable Polio (Salk):
Measles (Hard Measles, Red Measles, Rubeola):
Mumps:
Rubella (German Measles, 3 Day Measles):
Other:
Tuberculin Test Given:

Top of Page