Campfirmation Registration 
July 8th - 13th, 2018
$325
NEW LOCATION!!!: The Springs (UCYC) Prescott, AZ 
Save & Return Account (optional)
CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form.
Please complete this online form in its entirety no later than May 25, 2018.
Have you previously attended Campfirmation? *
Registration Deadline: May 25, 2018

Household / Adult Primary Contact

Parent(s)/Guardians(s) info: Please fill out every blank, if you need to type: NONE *
 Parent/Guardian #1Parent/Guardian #2
Name
Work Phone
Cell Phone
Alternate Contact Information (please provide at least two names)
Please fill out every blank space. If needed, type "NONE". *
 Alternate Contact #1Alternate Contact #2
Relation to Youth
Name
Phone Number

Health History Record

Youth Information
In the event of an illness or injury during camp, your insurance information will be provided to the health care professional(s).
Health Insurance? *
Chronic and Recurring Illnesses
 
Other Health Conditions
 
List all Allergies and specify reactions
Any prescription or over-the-counter medication must be left with the "Camp Nurse".  Medication may only be left at camp if the medication is in the original over-the-counter or prescription container, and has detailed written instructions for administration.  Medications in a baggie or similar container will be refused.
For comfort care of minor illnesses/injuries, my child may receive the following: *
 
Are there any activity restrictions? *
 

Medical and Liability Release Statement

This health history is correct so far as I know.  I hereby give permission to camp medical/first aid personnel or Camp Director to provide routine health care and emergency first aid; to release any records necessary for treatment or insurance purposes, and to provide or arrange necessary transportation.  I understand that my insurance information will be given to any healthcare providers, but that I will ultimately be responsible for any medical charges in the case of illness or injury while my youth is participating at Lutheran Campfirmation.  In the event I cannot be reached in an emergency, I hereby give the permission to the physician selected by the Camp Director to secure and administer treatment, including hospitalization, for the person named above.  I understand that the camp health supervisor is present 24 hours a day, but a physician is not present.  I agree to travel to Prescott to attend to my child and/or to transport my child home for fever, vomiting or as deemed necessary by the Camp Director.

I understand that participation in this event is not without risk to my child because of the group nature of the event and the unpredictable behavior of any group, even when managed with the greatest amount of care.  I understand that all reasonable safety precautions will be taken at all times by Lutheran Campfirmation.  I understand the possibility of unforeseen hazards and know the inherent possibility of risk.  I agree to not hold Lutheran Campfirmation, its leaders, employees, volunteers or your home church liable for damages, losses, diseases, negligence, or injuries, or death incurred by my youth. 

Payment Information

Payment
All payments for Campfirmation will be handled through your home church. Please submit your payment to your pastor, youth director, or your church office by the deadlines that are specified by your home church.  All checks should be made payable to your home church as well. 
By checking Yes, you are agreeing to the terms listed above.  Checking Yes acts as your electronic signature. *
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