KIDZ POWER
KAMP
Camper ‘s Full Name:__________________________Gender___
Date:_________________________
Parents’ Application for Enrollment
Fill out completely and send with deposit check for $100 made
out to Healing Forest Foundation
Mail to: Healing Forest Foundation 5830 Plantation Drive, Roswell,
GA 30075
Please register:______________________________for the following
session:_________________
1st Session (June 18-25) for Girls & Boys ages 13-17 tuition
$795
2 ndSession (July 23-30) for Girls & Boys ages 3-12 tuition
$795
Date of Birth:______________________Age in Years:____Months:_____(at
time of camp session)
Parent’s Names:________________________________________________________________________
Mailing Address: ________________________________________________________________________
City:__________________________________State:______________________Zip:__________________
Home Phone:_______________________________Business Phone:______________________________
Cell Phone:_________________________________Fax:________________________________________
Email Address:_________________________________________________________________________
Parents attended Essence of Being Workshop (last date):_______________________________________
Insurance Carrier (please attach a copy of insurance card)____________________________________
Physician’s Name:_____________________________ Phone: __________________________________
Person to contact in case of emergency should parents not be
available:____________________________
Telephone numbers:_____________________________________________________________________
Relationship to camper:___________________________________________________________________
School Attending:___________________________________________Grade
Entering in Fall___________
Religious Affiliation:______________________________________________________________________
Height:_______________Weight:___________________T-Shirt Size:_______________
A reservation fee of $100 must accompany this application. This
is credited toward the total fee. $50 of the reservation fee will
be refunded in case of cancellation NOT LATER THAN March 31st.
I give Healing Forest Foundation and Kid Power Camp permission
to use in its catalog, video, or on its website any camp picture
in which the likeness of my son or daughter appears. Also, I hereby
give permission to the physician selected by Kidz Power Kamp to
hospitalize, secure proper treatment for, and to order injections,
anesthesia and surgery as needed for my child names above. I have
read and agree with the terms of enrollment as stated with this
application.
Signed: (parent or guardian)_____________________________________________Date:____________
CONFIDENTIAL PARENT INFORMATION
Does your child want to come to camp?_______________________________________
Has he/she been a camper elsewhere?____When?_________Where?______________
Does you child have siblings?_______Please list Names & Ages
below
Name_____________Age____ Name_____________Age____ Name_____________Age____
Name_____________Age____ Name_____________Age____ Name_____________Age____
Does your child meet people easily?____________________________________________
What is your child most looking forward to in her/his camping
experience?______________
________________________________________________________________________
Does your child have any learning, physical, or emotional difficulties
that we should be aware of? If so, please give a brief explanation_______________________________
_______________________________________________________________________
What, if any, camp activities should be avoided?_______________________________
______________________________________________________________________
Does your child need special medication?_____________If so, what?________________
________________________________________________________________________
Is your daughter allergic to any medication, food, etc.? _______
If so, what? ____________
_______________________________________________________________________
Will your child need a special diet?____________ If so, what?_______________________
________________________________________________________________________
Does your child swim?______________________________________________________
Please include any suggestions that will be helpful to the staff
members in giving your child a happy, worthwhile camping experience.
PLEASE INCLUDE ALL MEDICAL INFORMATION ON THE ENCLOSED FORM. ALSO,
PLEASE SIGN THE ATTACHED WAIVERS AND BRING TO REGISTRATION. CHILDREN
WITHOUT WAIVERS SIGNED BY THEIR PARENTS WILL NOT BE ABLE TO PARTICIPATE
IN CAMP ACTIVITIES.
Parent Feedback:_____________________________________________________________
Camper Application
Name: ________________________________________
Name you like to be called: _________________________
Email address: __________________________________
I think that Kid Power Camp is ______________________
My favorite activities and hobbies are _________________
_______________________________________________
My favorite area in school is ________________________
NOT MAYBE TOTALLY
Fun loving ? ? ?
Smart ? ? ?
Attractive ? ? ?
Good Grades ? ? ?
Shy ? ? ?
Friendly ? ? ?
Confident ? ? ?
Communicative ? ? ?
Active ? ? ?
Trusting ? ? ?
Coordinated ? ? ?
Loving ? ? ?
Please rate yourself in the following categories
Sometimes I have any challenges with adults, teachers, parents.
These are _________________________________________
Sometimes I have any challenges with other kids.
These are ___________________________________________
In the future, I plan to ___________________________________________________________________
If I could change one thing about myself it would be ____________________________________________
If I could change one thing about my parents, it would be ________________________________________
If I could change one thing about the world it would be __________________________________________
I believe that my special gift(s) are _________________________________________________________
I want to help teach people that ________________________________________________
One thing that I think that everyone should know about me is
KIDZ POWER KAMP
HEALTH CERTIFICATE
Child’s Name _________________________________Date of Birth___/____/___
First Middle Last Mo. Day Yr.
Gender ??____ Male ____Female
Street Address _____________________________________________________
City_____________________State_________________Zip__________________
Parent’s Name______________________________________________________
Telephone (home)______________________(work)_______________________
Email address _______________________ (cell)_________________________
“I hereby give permission to Four Winds Peace Center and
Kid Power Camp to secure emergency medical and surgical treatment
and routine non-surgical medical care for my child while in camp
(including aspirin, acetaminophen, ibuprofen, and prescription
drugs.)”
Signed________________________________________Date________________
Other emergency name and phone # __________________________________
Insurance Company______________________Policy Number______________
Child’s Doctor’s Name____________________Doctor’s
Phone #____________
Allergies he/she has_________________________________________________
Diseases he/she has had_____________________________________________
Other (e.g. epilepsy, asthma)__________________________________________
Medication presently being used_______________________________________
Special conditions:
Reactions to Drugs____________Sleepwalking___Bedwetting___Fainting___
Other____________________________________________________________
IMMUNIZATION
RECORD POLIO DIPHTHERIA TETANUS WHOOPING COUGH MEASLES RUBELLA
Date of latest __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__
__/__/__
INNOCULATION |