CAMP BELLEVUE

August 1-5, 2011

A joint venture of Camp Fowler and Bellevue Reformed Church

For Bellevue area children

who are entering 3rd - 7th grade
Send registration and payment to:
Bellevue Reformed Church
2000 Broadway
Schenectady, NY 12306

Registration Deadline: July 20

REGISTRATION
(limited to 40 campers)

Name _________________________________________

Male ______ Female _____

Birth Date ___________________________ Grade (Fall 2011) ___________________

Address ________________________________________________________________
City _______________________________ State ______ Zip ______________________
Home Church (if any) ______________________________________________________
T-Shirt Size (circle) Child S M L XL

Adult S M L XL

EMERGENCY C0NTACTS
Parent/Guardian: _____________________________ Phone: ___________________
Parent/Guardian: _____________________________ Phone: ___________________
Other: ________________________________________ Phone: ______________________
Order in which to be called: Mother _______

Father __________

Other __________

PAYMENT
The cost of the camp is $40 per camper. For those unable to pay the full amount, we ask that
you contribute whatever your budget can handle between $15 and $40 per camper. If possible,
include your entire payment with your registration (or at least $15 per camper).
I have enclosed $ ____________.

(Registration Deadline: July 20)

THURSDAY NIGHT DINNER AND PROGRAM

I (we) will be attending the dinner and program on Thursday evening (5:30 7:30): Yes ___ No ___
Number of non-campers attending the dinner (maximum of 2): _________

INFORMATION FOR RELEASING CAMPER AT END OF DAY

Camper is able to walk home on his/her own: Yes _____

No ______

Names of person(s) allowed to pick up camper (BE SURE YOU OR OTHERS BRING ID!)
_____________________________________________________________________________
_____________________________________________________________________________

AFTER CAMP SUPERVISION

We understand that because of work schedules, it may not be convenient for some children to
be released or picked up at 4:00. An after day camp supervision is available from 4:00-5:15 for
an additional cost of $4.00 per day, or $16 for the week.
I would like to register my child for the after day camp supervision: Yes ____

No _____

I have enclosed $ ________ to pay for the after camp program.

If possible, note the days your child will be needing the after camp supervision (on Thursday all
campers will be staying through dinner and the evening program):
Monday ______ Tuesday ______ Wednesday _______ Friday ______

CAMPER MEDICAL RECORD

HEALTH INSURANCE
Bellevue Reformed Church provides secondary accident coverage. Your insurance will be the
primary coverage.
None _________________
Your Company________________________________________________________________
Group #___________________________________Identification #_______________________

IMMUNIZATIONS
Please list dates or include separate form from school or doctor.
Dose Admin.
DPT

Date Admin.
Dose
Date
1st __________
MMR
1st __________
2nd __________
2 nd __________
3rd __________
OPV
1st __________
st
Tetanus (td)
1 __________
2nd __________
latest__________
3rd __________
Meningitis if given __________________________
Hepatitis B
1st __________
2nd __________
3rd __________

MEDICAL HISTORY(Mark N/A if none)

Food Allergies (list)_____________________________________________________________
Medication Allergies (list)________________________________________________________
Insect Allergies (list)____________________________________________________________
ADHD_______________________________________________________________________
Physical Limitations____________________________________________________________
Asthma______________________________________________________________________
Learning Disabilities____________________________________________________________
Fainting______________________________________________________________________
Serious Operation__________________________ Date____________ Type_______________
Other________________________________________________________________________

NO MEDICATIONS WILL BE ADMINISTERED BY THE CAMP NURSE WITHOUT WRITTEN

AUTHORIZATION FROM THE CHILDS PHYSICIAN AND PARENT OR GUARDIAN. CALL
THE CHURCH OFFICE (393-1341) IF YOU NEED A PHYSICIAN AUTHORIZATION FORM.

RELEASE INFORMATION
My signature below certifies and gives permission that:
1. All information given is correct.
2. Photos of my child can be used in camp publicity.
3. My child can be transported for camp activities.
4. My childs medical records can be released in case of illness/injury.
5. In the event I cannot be reached, I give permission to the Physician selected by the Fowler
and Bellevue Reformed Church staff to hospitalize, select treatment for, order medications,
anesthetize, and/or perform surgery on the child named above.

Parent/Guardian Signature:______________________________________________________
Date:________________________________________