SERTOMA
CAMP ENDEAVOR
JULY 10TH - JULY 16TH TEENS
JULY 17TH - JULY 23RD YOUTH
Summer 2022 Covid 19 Update
Camper Registration
*
Child's First Name
*
Child's Last Name
*
Parent/Guardian's Primary Email
*
Date of Birth
Age at Camp
13
*
Gender
Male
*
Name of Current School
*
Current Grade
*
Child is:
Deaf
Hard-of-Hearing
CODA
Sibling of D/HH
*
Child lives with:
Mother
Father
Guardian
Other
Mother/Guardian's Name
Mother's Address
City
State
Country
Postal Code
Phone Number
Phone Type
Video Phone
Text
Voice
Father/Guardian's Name
Father/Guardian's Address
City
State
Country
Postal Code
Phone Number
Phone Type
Video Phone
Text
Voice
Has your child ever attended camp before?
Yes
No
Indicate your child's swimming experience:
Beginner (stays in shallow water)
Intermediate (stays in water below shoulder)
Advanced (can swim freely in deep water)
Child's T-Shirt Size
Child Small
*
Child's Health Insurance Company
*
Policy # or Medicaid #
SS#
*
Height
*
Weight
Anything we should know?
*
1st Emergency Contact
*
1st Emergency Contact Phone #
*
2nd Emergency Contact
*
2nd Emergency Contact Phone #
Family Medical Doctor (Name and Address)
Street Address
City
State
Country
Postal Code
*
Assistive Devices Child Uses
Cochlear Implant
Hearing Aid
Other
None
*
Child's Communication Modes
Sign Language
Gestures
Speech
Other
*
Medical History
ADD
ADHD
ALLERGY TO ENVIRONMENT
ALLERGY TO FOOD
ALLERGY TO INSECT STINGS
ALLERGY TO MEDICATION
ASTHMA
HIGH/LOW BLOOD PRESSURE
BEDWETTING
BROKEN BONE
CONSTIPATION
DIABETES
DIARRHEA
EAR INFECTIONS
EATING DISORDER
EPILEPSY
HEADACHES
GLASSES/CONTACTS
HEART PROBLEMS
LUNG PROBLEMS
PSYCHIATRIC COUNSELING
SKIN PROBLEMS
OTHER
NONE
Please explain any boxes checked above:
List all medications prescribed by doctor:
Any activity restrictions prescribed by doctor:
Does your child need assistance with any of the following:
toileting
showering
eating
dressing
Any additional disabilities/special needs? Please explain:
Anything we should know?
How did you hear about Sertoma Camp Endeavor? (check one)
Our website: www.campendeavorfl.org
from a friend or family member
Facebook
School
Other
My child may participate in any camp-sponsored field trips away from Sertoma Camp Endeavor premises and be transported by vehicle driven by designated licensed staff.
Yes
No
SUBMIT
Camp Endeavor 2022 Boys Ages 13-17
Jul 10, 2:00 PM – Jul 16, 11:00 AM
Camp Endeavor
