Register for Dream Kamp 2018!

For three weeks, our Dream Kamp will provide daily age-appropriate sessions that focus on community responsibility, self-esteem, self-perception, goal setting and accountability, exercise and fitness, life skills, college prep and job readiness training.

We look forward to having you!

Section 1

Kamper Information

Main E-Mail for Correspondance*

Kamper First Name*

Kamper Last Name*

Kamper T-Shirt Size*

Kamper School*

Kamper Grade*

Kamper Date of Birth* (00-00-0000)

Kamper E-Mail Address*

Phone Number

Kamper Address*

City*

State*

Zip Code*

Section 2

Kamper Parent/Guardian Information

Emergency Contact #1*

Relationship*

Emergency Contact Phone #1*

Emergency Contact #1 E-Mail*

Emergency Contact #2

Relationship

Emergency Contact Phone #2

Emergency Contact #2 E-Mail

Section 3

Kamper Health Information

The information you provide here will be held in the strictest confidence. It will be kept on file in our health binder or carried by the camp director when your child travels on the campus with one of our camp groups.

Child’s doctor’s name

Child Doctors Phone Number

Allergies?*

If yes, please describe the severity of the reaction , requested accommodations and what is done to manage them.

Does you child have an allergic reactions to sunscreen?*

May we Serve Your child food and beverages?*

Medical, physical or emotional conditions (including Disabilities):
If your child does have any conditions, please provide information to assist us in providing the best camp experience for your child.

Medical, physical or emotional conditions (including Disabilities):*

Medications (including inhalers)*

Is your child up-to-date on all state-required immunizations?*

If your child must take medication while at camp, please note here. All medications must be in their original containers and be appropriately labeled. Please do not give your campers medication to them to bring to camp; medications must be received and held by the camp office or with the camp director.

Medications (including inhalers)

Section 4

Insurance Information

Is the participant covered by family medical/hospital insurance?*

Insurance Carrier or Plan Name

Insurance Group Name

Insurance Address

Insurance City

Insurance State

Insurance Zip Code

Name of Insured

Relationship to participant

Section 5

Consent & Contract

Authorization of Consent
(I) (we), the undersigned Parent(s)/ Guardian(s) do herby authorize an hospital for the undersigned to consent to any X-ray examinations, anesthetic, medial or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of , any physician and/or surgeon licensed under the provisions of the medical practices act. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician or dentist, in the exercise of his/her best judgement, may deem advisable.

Individual Contract
To the extent allowed by law, I , the undersigned am the parent/guardian f the individual(s) named below, and shall hold harmless, indemnify, and defend Dream Keepers, Inc., the trustees of Dream Keepers, Inc. and the officers, employees, volunteers and agents of each of the from and against any and all liability, loss, damage, expense, cost of every nature and causes of actions arising out of or in connection with any negligent in the performance of this agreement. It is further understood and agree that this waiver, release and assumption of risk to be binding on my heirs and assigns. I also release Dream Keepers, Inc. of liability for any claims that may arise out of activity. Dream Keepers, Inc. also reserved the right to remove participants from the program if they present a threat to the children or if they abuse the privilege of the mission statement of Dream Keepers, inc. I also understand that participation in the program can cause severe injury or death and I have taken care to enroll at the level of his/her/my/our physical abilities and/or medical conditions. I hereby grant permission to Dream Keepers, Inc. to take my photo while participating in the activities to us for publicity. One parent/guardian must sign for all minors online and in person.

I have read this entire informed Consent Agreement. I fully understand it and agree to be legally bound by it.

Electronic acceptance of Parent/Guardian*

Send me a copy

Subscribe to our newsletter