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CAMP COST
Non-prescription medication
for Minors
MEDICAT CONSENT
STRUCTURE
(Includes 3 meals/day & lodging for the
Good health, no allergies or special medical condition,
weeÐ
Each Camper 13 and
is (am) in
Mychild, (I)
OR
over
8225
Children 5 to 12 years
$150
Children under 5 years
Free
COMMUTER COSTS
(Commuters are individuals who visit for a day
or two rather than stay at the Camp for the
week)
My child (I)
IS
[ ]Asthma [ ]Fainting/Convulsion
[ ] Heart Troubles [ ] Severe reaction to Bee sting
[ ] Diabetes [ ] Tubes in ear.
Immunization: [ ]Tetanus[ ]Polio
[ ]Measles/Mumps/Rubella [ ]Diphtheria
(D
If your child suffers from a minor
yhich does not require a
doctor's ',¡orsit, it may be appropriate to
ailment,
Signature:
t2
Date:
administer non-prescription medications.
"6 "f,¡ "6 "6 "6
(lncludes three meals and overnight lodging)
-
(D
Name of parenlguardian
Daytime Registration
5 to 12 years
$35.00 per day
13 years and over $50.00 per day
ffiffi
(am) not in
good health, in addition, is subject to the following:
Medical Report FoRALtcAMPERS
(To be completed and signed by a physician.)
Please check the boxes below with the
medications we have your peÍnission to
administer.
Please select and complete the choices(s)
QUESTIONS?
Camp Director: Jermaine Bell
-
718-657-7699
Email: belljerms@aol.com
Registration: D. Pommells -7 18-657 -7 699
Email: dpommells@gmail.com
New
T0il( Irlelr0 Dislfi0l Famlly 0amp
Rev. Jermaine Bell,
Camp Director
155-15 90'h Avenue
Jamaica, l'|Y 11432
[ ] Sudafed
[]
f I Camoer.
. is in sood health. No
allersies or no sDeclal medrcal condltlon or cllagnosls
and íf a minor tËe immunization record is comõlete
(date),
and up to date as o{_
[ ] Expectorant/Cough Suppressant
I
[ ] Diarrhea
1S
with
a
statins the
if anyi 1S
Mail Registration Forms & fees fo.'
Tylenol
applicable to the camper.
I
campef.
1S A IIUnOr
I Camper,
whose immunization record is incomplete
(date)
and/or needs to be updated as of
Siguature ofphysician
Emergency #
[ ] Decongestant/Ana
histamine
Medication
[ ] Throat spray/ Lozenge
[ ]Ibuprophen [ ]Tums
Signature of Parent/ Guardian
Date:
t2
REGISTRATION FORM
NEW YORK METRO DISTRICT
FAMITY CAMP 2012
REGISTRATION FORM
Medical Release: This health history
is correct as far as I know, and
Name:
Age:
thê
Derson herein described has nermission
Gender:
Address:
prescribed ÑY Metro
to ensase in all 'activities
FamiÍv" Camn
exceot as
noted.'In the eient I cannot be réached
in an emergency, I hereby give
nermission to" the selected dottorY to
hospitalize.
' secure proþer treatment
for,^ and to ordei ìniection and
or/surserv for the camper name in this
Theme: *PERSUADED'
Date:
for medical fees or
prescriptions and that I am solely
iesponöible for any and all such feeï
and charges arisiñg from illness or
Telephone:
Body soap/wash
Catskill, NY 12414
Deodorant, Perfume, Cologne, Powder
Tissue paper
Wash rags
VIA NEW YORK STATE THRUWAY:
Rubber slipper
Take Exit 21, turn right at traffic light on to 238, continue on to
Leeds, then right at Green Lake Road. lt's just 3 miles to GREEN
LAKE RESORT
For Children under the age of
18
yrs old:
Have you ever attended NY Metro
District Camp?
Yes-, No-.
Supervising adult at Camp
Parent/Guardian Signature
Liabilitv Release: The undersisn. for
himself" or herself and ne"rs'onal
representatives, assigns, heirs änd next
of* kin (herein referr"ed to as releasors\.
herebv rreleases. í¡¡aives. discharses anil
covenänts not' to súe NY Ïetro
Familv Camp.' its asents. servants and
emnloíees ^ (herein ré{erred to ûs
Registration Deadlin
1.
2.
t2
"z
4
Each Church is responsible for the
transportation of their members lvisitors
to and from Camp.
Commuters [i.e. individuals who plan to
onlyvisit the Camp rather than stay on
Campus] must also register by the above
deadline.
3.
4.
Date
luly 3l*
Special Instructions:
from all liaËilitv to
the
releasolé for all losses or dãmase and
any claim or demands on acco"unt of
ini"urv to the Derson or nrooertv or
le"suilinq fi'om ^death of the ieleásors
whetherY caused bv the neslisence of
the releasees oí otherr.,iìsã while
narticiuatins in activities associated
'with the releasees to the ftrllest extent
of the law. The undersisn is fullv aware
of the inherent hazaid and "hereby
elects to narticinate voluntarilv antl
assume alf risk'of loss. damíee or
jnjury that may be sustain by him or
her.
relàaseies\.
Shower caps
Bathrobe
Shampoo, comb, brush andhair
Applications Due by:
Special Requirement
& Towels
accessories
Email:
Pastor's Signature:
Dental Floss
605 Green Lake Road
rnlur.y that may occur.
Church
Toothbrush & paste
Mouthwash
GREEN LAKE RESORT
Directions:
resistrãtidn form. I understand that the
NY Metro F4mily C.u-p does not
nrovide
medical rnsurance or
'reimbursement
Personal Hvgiene Items
August 13th- l8th,20l2
Location:
Checklist For Items Needed
Al1 campers and commuters need to have
the medical report completed and signed
by a physician or the medical consent
signed by a parentlguardian.
The camper's Pastor as well as the other
required signatory must sign each form.
Clothine Needs
Sleepwear
Casual outfits
Clothes for evening services
Shoes for evening services
Spring jackets
Sneakers for sporting activities
General Needs
Bible, pens, pencils
Bed linen-sheets
Pillow and cases
Light blanket
Flashlight, Umbrella
NIGHT LIGHT
(Especially for small children)
ltEw Y0RK ilErno
DISÌRICI