Register for Camps at CMMBC!

Name of Camper *

First Name

Last Name

Register for camp(s) selected below *

Soccer Camp (Upcoming Grades K-8)

Arts Camp (Upcoming Grades 2-6)

Pathfinders Camp (Upcoming Grades K-5)

Trailblazers Camp (Upcoming Grades 4-7)

Senior Camp (Upcoming Grades 8-12 and Seniors who have just graduated)

Name of Parent/Guardian *

First Name

Last Name

Name of Parent/Guardian

First Name

Last Name

Newsletter Updates

Please add my name to the Mailing List for the quarterly newsletter, CMMBC News

Phone 1 *

(###)

###

####

Phone 2

(###)

###

####

Address 1

If different from camper address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Emergency Contact *

First Name

Last Name

Emergency Phone Number 1 *

(###)

###

####

Emergency Phone Number 2

(###)

###

####

Date of Birth *

MM

DD

YYYY

Child's Doctor's Name *

First Name

Last Name

Doctor's Phone Number *

(###)

###

####

Health History

If the answer to any of these questions is "yes", please check the box in front of the condition and provide additional information as appropriate below

Diabetes

Seizures

Allergies

Allergy Shots (desensitization)

Glasses

Contact Lenses

Hearing Aids

Are vaccinations current? *

Yes

No

I don't know

Has She Menstruated?

Yes

No

If No, Does she know about it?

Yes

No

For Fever/Pain

Acetaminophen (Tylenol)

Ibuprofen (Advil)

For Cold/Allergies

Diphenhydramine (Benedryl)

Pseudoephedrine Hydrochloride (Sudafed)

Loratadine (Claratin)

Fexofenadine (Allegra)

For Stomach

Calcium Antacid Tablets (i.e. Tums)

Bismuth Subsalicylate (Pepto Bismol)

Loperamide (Immodium)

For Topical Treatment

Antibiotic Ointment

Burn Ointment

Calamine Lotion

Hydrocortisone Cream

Sting Eze for insect bites

Chloraseptic Spray

Cough Drops

Parent/Legal Guardian Authorization - E-Signature --- My e-signature below indicates that the above named camper has permission to engage in all camp activities (unless noted otherwise) on and off camp grounds, and to be transported to and participate in, excursions off camp grounds (including swimming), under the supervision of CMMBC staff. I understand that campers are expected to comply with camp rules, and any camper disregarding camp rules is subject to being sent home with no refund of camp fees. I give permission for the CMMBC staff to: (1) provide routine health care (including medication) for the above named camper. I understand all medications, including over-the-counter, must be kept by the nurse. If deemed necessary, I authorize them to obtain services of medical professionals and to provide necessary related transportation. I authorize any physician and any hospital, through its medical staff, to take appropriate measures. I understand that I am responsible to pay my child's medical care, including any emergency care authorized in this section. I agree to the release of these records for insurance purposes and/or as requested by a physician for the care of my minor child. The camp will make reasonable efforts to notify parents promptly if measures other than routine care are taken. (2) photograph and record this child and to use his/her images and sound prints in promotional materials for CMMBC including newspaper and internet. (3) use of a photocopy of this form and/or electronic signature as my authorization *

First Name

Last Name

Camper Agreement - E-Signature --- I understand the importance of, and will adhere to camp safety regulations and the directions given to me by camp leaders so they can provide me and all campers with a safe, pleasant and memorable camp experience. I will be sure to give all medications to the nurse. I will leave my electronic devices at home or turn them into camp staff upon check-in at camp. I understand that if I fail to follow camp rules, I may be sent home. *

First Name

Last Name