Select Registration Type
*
Camp (ages 7 - 12)
Leadership 101 (ages 13+)
Counselor
Camper's Name
*
First Name
Last Name
Name Camper Prefers
Camper's Age
*
7
8
9
10
11
12
13
14
15
16
17
18 or older
Date of Birth
*
MM
DD
YYYY
Camper's Assigned Sex at Birth
*
Male
Female
Camper Identifies Gender As
*
Male
Female
Non-Binary
Other
If selected "Other," please state gender identity here
Camper T-shirt Size
*
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Parent/Guardian Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian Phone
*
(###)
###
####
Parent/Guardian Email
*
Primary Emergency Contact & Relation to Camper
*
Primary Emergency Contact Phone
*
(###)
###
####
Alternate Emergency Contact & Relation to Camper
*
Alternate Emergency Contact Phone
*
(###)
###
####
Primary Care Doctor's Name
*
Primary Care Doctor's Phone Number
*
(###)
###
####
Medical Insurance Company
*
Insurance Policy ID Number
*
Date of Last Tetanus Shot
*
MM
DD
YYYY
Does your camper have any food allergies or dietary restrictions? If yes, please explain.
*
Please list any medical conditions treated by a doctor in the last year.
*
Has your camper experienced any of the following?
*
Details from Above:
Please indicate the dates of illness, severity, complications, and any residual impairment of any of the above items.
Camper's Medications
*
Please list all medications your camper is taking.
During camp, medication will be administered to campers as directed by a physician. The Cabins4Kids Camp will do everything in its power to prevent incorrect medicine from being given. However, Cabins4Kids is not liable for incorrect medicine provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medications, bottles and dosages at the time of registration. This is not the time to give medication vacations to your child.
Please include the following with each medication:
Name -
Prescribed For -
Dosage/Amount -
Time(s) Given -
Please check which, if any, medications Cabins4Kids medical professional(s) have permission to administer to my camper.
*
Please call me before giving my child any over the counter medication.
*
Yes
No
I understand participants will be supervised and that, if serious illness or injury develops, medical and/or hospital care will be given. I hereby give my permission to the attending physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child and affirm that the information set forth in the Health Form section is true and correct to the best of my knowledge.
*
Release Statement
*
I hereby release the Cabins4Kids Organization, officers and employees, from all claims, demands, and causes of action of any kind, including claims of negligence, which may arise from participation of my minor child in any Cabins4Kids sponsored activity, and this release is specifically granted in consideration of the services, programs and activities, and being allowed to participate.
Cabins 4 Kids does not assume liability of any other person(s) or entities.
Youth Code of Conduct
*
Please review the Youth Code of Conduct with your camper. Upon submission of this registration form, it is expected that your camper has read this Youth Code of Conduct and agrees to abide by it.
As a participant in Cabins4Kids events, you have the responsibility of representing Cabins4Kids to the public. You are expected to conduct yourself in a manner that will bring honor to you, your family, and Cabins4Kids. To do that you must:
1) Attend all sessions in the planned program. If you are unable to attend please tell the adult in charge.
2) Follow hours and room rules established before the event begins and you are responsible to know the rules for each event.
3) Dress appropriately for each event. The adults in charge should have guidelines to help you.
4) Be responsible to know and use language and manners appropriate for Cabins4Kids.
5) Be in the assigned program area (for example: dorms, cabins, motels, etc.) at all times.
6) Know that the use of tobacco, alcohol and non-prescribed drugs is illegal and prohibited at Cabins4Kids events.
7) Model respect for other persons, facilities and vehicles. You will be personally responsible for any damage caused as a result of your behavior.
8) Help other members in your group have a pleasant experience by making every attempt to include all participants in activities.
9) Know that harassment of any type is illegal and prohibited at all Cabins4Kids events.
10) By typing the camper's name below I, and my camper, acknowledge that we have read the Cabins4Kids Youth Code of Conduct and agree to live up to the expectations. We realize that the failure to do so could result in loss of privileges during the event and/or in the future.
How did you hear about camp?
*
If answered "other", how did you hear about camp?
Select Payment Option
*
Can pay full $225
Requesting partial scholarship (can pay $112)
Requesting full scholarship
If paying, please select method of payment.
PayPal - Click "Support Us" then "Donate" (or send to cabins4kids@gmail.com)
Check/Cash - mail to 3542 NE Rock Creek Dr, Kansas City MO 64116
