Freedom Kids Summer Camp Pre-Registration Form 2025

Kid's Camp is June 9-13 for kids who have finished 1st, 2nd and 3rd Grades.
Pre-Teen Camp is June 16-20 for kids who have finished 4th, 5th and 6th Grades.
$220 for Campers registered before May 1st.
$250 for campers registered between May 2nd and June 1st.
(T-shirt sizes are not guaranteed after May 15)
$280 for campers registered after June 1st.
(T-shirt not guaranteed for registrations after June 1st)
NO WALK UP REGISTRATIONS.

Camper's Name:

Camper's Gender
Choose OneFemaleMale

Grade Level Completed in School
Choose OneFirstSecondThirdFourthFifthSixth

Date of Birth

Roommate/Counselor Request (understand this is a request and space availability may require it not be honored)

Parent/Guardian 1 Name

Parent/Guardian 1 Best Contact Number

Parent/Guardian 2 Name

Parent/Guardian 2 Best Contact Number

Best Contact E-mail

Home Street Address

City

State

Zip Code

Church Name

T-Shirt Size (Not guaranteed if requesting after May 15)
Choose OneX-SmallSmallMediumLargeX-LargeXX-Large

Medical History

Special Needs Diagnosis (if any)

Primary Doctor

Dr Office Number

Insurance Company Name

Insurance Policy Numbers

Date of Last Tetanus Shot

List all known medication allergies (if none, leave as none)

Any other allergies? (if none, leave as none)

Please list any special dietary needs (if none, leave as none)

Please Check Any Current or Past Medical Problems
NoneAppendix RemovedHeart ProblemsAutismADD or ADHDAsthmaDiabetesFainting SpellsSeizuresHIV PositiveProstheticsBed WettingSleep WalkingBleeding/Clotting DisordersFrequent Ear InfectionsHypertensionOther

The following over the counter medications are kept on hand and administered at the discretion of the camp nurse:
Acetaminophen (Tylenol), Ibuprofen (Advil/Motrin), Loratadine (Claritin), Diphenhydramine (Benadryl), Antibiotic Creams/Ointments (Neosporin), Anti-Itch Creams/Ointments (Hydrocortisone Cream 1%), Calamine Lotion (generic), Sore Throat Spray, Cough Syrup and/or cough drops, Laxative (Ex-Lax), Gas-X (generic), Anti-Diarrhea Medication (generic Pepto Bismol), Antacid (Tums, generic), Aloe, First Aid (pain relief) spray, wound cleansing agents.

Based on the above list, choose whether you want the nurse to administer as needed medication:
Choose OneNurse Meds are OKNurse Meds NOT OK

My child should not be administered the following over the counter medications:

If prescription medications are to be given at camp, please complete the Authorization to Administer Medication Form. Your child cannot maintain possession of medications. They must be held at the nurses station.
My Camper does not take daily prescription medication.Please e-mail me the Medication Authorization Form.My child needs to have an EpiPen with them at all times.My child needs to have an inhaler with them at all times.

Please describe the condition requiring the use of an EpiPen or inhaler. Understand the device will be kept by the counselor and available at all times.

I give permission for my child (name listed in this form) to be treated by the camp nurse. This may include, but is not limited to, upset stomach, headaches, bumps and bruises. I also give consent for my child to be taken to a local ER for any major issues. I understand that I will receive a phone call before or while my child is being transported to receive emergency care.
Choose oneYesNo

List up to two (2) people authorized to pick up your child from camp in the case of an emergency. These will also serve as additional emergency contacts.

Name and Relationship

Contact Number:

Name and Relationship

Contact Number

REFUNDS: No refunds will be issued after camp begins. The only exception is due to illness on FIRST DAY OF CAMP.
ChooseUnderstood

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above release statements.
Yes

I understand that I will be providing, as proof of identity, the last four (4) digits of my social security number.
Yes

Signature of legal guardian (Type first and last name):

Provide last four (4) digits of your SSN#:

Today's Date:

When you press SUBMIT, you will be redirected to a payment page to complete the $50 deposit. If you fail to submit the payment, your preregistration will not be completed.