2008 Online Registration

You must submit a SEPARATE FORM for EACH WEEK of camp you wish to attend. 

The Fire Marshall limits our cabin occupancy to 16 persons in each cabin. Please register early to ensure a place.

Items marked with a red asterisk (*) are required, however, we ask that you make every attempt to fill out ALL fields.

*PLEASE SELECT A PREFERRED WEEK OF CAMP:

Regular Overnight Weeks
Week 1 - Phillip Satterfield, Macland Road Church of Christ (June 1 - June 7)

Week 2 - Greg Nash, Fayettville Church of Christ (June 8 - June 14)

Week 3 - Johnny McDaniel, Bremen Church of Christ (June 15 - June 21)

Week 4 - Tommy Tidwell, South Cobb Church of Christ (June 22 - June 28)

Junior Day Camp Week
Jr. Week - Jonathan Stroud, South Cobb Church of Christ (July 7 - July 11)

CAMP COOKBOOK:

Would you like to add a Camp Cookbook to your registration for only $10? All the proceeds benefit Camp Inagehi.

Camp Cookbook - $10

YES! Add a Camp Cookbook to my registration

CAMPER INFORMATION:
*First Name *Last Name Nick Name

*Date of Birth (MM/DD/YYYY)
*Age at Time of Camp

*Gender
Male    Female  

*Address


*City *State *Zip

*Home Phone


Camper Email (if applicable)
Add to Mailing List     Yes     No   

Home Church/Congregation


*T-shirt Size
YS     YM     YL     S     M     L     XL     XXL   

PARENT/LEGAL GUARDIAN INFORMATION:
*First Name *Last Name *Relation to Camper


Employer
Phone
Mobile Phone

*Email
Add to Mailing List     Yes     No   
The above email address is where your copy of this registration form will be sent.

First Name Last Name Relation to Camper


Employer
Phone
Mobile Phone

Email
Add to Mailing List     Yes     No   

RESPONSIBLE PERSON IN CASE OF EMERGENCY ROOM TREATMENT:

*First Name *Last Name *Relation to Camper


Employer
Phone

*Home Phone


Mobile Phone


*Primary Insurance Carrier


*Policy Number *Group Name *Group Number


ADDITIONAL EMERGENCY CONTACT:
*First Name *Last Name *Relation to Camper


*Home Phone


Mobile Phone


Employer
Phone


*First Name *Last Name *Relation to Camper


*Home Phone


Mobile Phone


Employer
Phone

PICK UP AUTHORIZATION:

Please list who is authorized to pick up your child from camp:

*First Name *Last Name *Relation to Camper




First Name Last Name Relation to Camper



First Name Last Name Relation to Camper




MEDICATIONS & SPECIAL NEEDS:

All medicines must be in original containers and clearly labeled.
Please remember that all medicines must be left with the nurse at registration.

Please list any medications you are aware of that your child will
need to take while at camp along with the frequency and dosages.


Please check any of the following over-the-counter medications
that you will allow the nurse to administer to your child as needed
Tylenol
Sudafed 		Ibuprofen
Cough Medicine 		Mylanta
Benadryl

Please list any medications your child is allergic to


Please list any other known allergies your child has (foods, bee stings, etc.)


Does your child have any special dietary needs (diabetes, etc.)?


Is there anything else you feel we need to be aware of (phobias, bed-wetting, etc.)?
Yes     No   
If yes, please explain

Are your child's immunizations up to date?     Yes     No   

ADDITIONAL COMMENTS:

Please state any additional comments in the space provided below

CONSENT AGREEMENT:


*I, the Parent or Legal Guardian, appoint the Director of Camp Inagehi and his staff as my agent to:

  1. In the event of sickness or injury, administer minor medical emergency aid or treatment which they shall deem appropriate for my child.
  2. In the event of sickness or injury, give consent to any emergency medical procedures, test or treatments for my child that they shall deem appropriate under the circumstances.

    Yes, I agree to the above statement