KIDZ POWER KAMP

Camper ‘s Full Name:__________________________Gender___ Date:_________________________

                        Parents’ Application for Enrollment

Fill out completely and send with deposit check for $100 made out to Healing Forest Foundation

Mail to: Healing Forest Foundation  5830 Plantation Drive, Roswell, GA 30075

Please register:______________________________for the following session:_________________

1st Session (June 18-25) for Girls & Boys ages 13-17 tuition $795

2 ndSession (July 23-30) for Girls & Boys ages 3-12 tuition $795

Date of Birth:______________________Age in Years:____Months:_____(at time of camp session)

Parent’s Names:________________________________________________________________________

Mailing Address: ________________________________________________________________________

City:__________________________________State:______________________Zip:__________________

Home Phone:_______________________________Business Phone:______________________________

Cell Phone:_________________________________Fax:________________________________________

Email Address:_________________________________________________________________________

Parents attended Essence of Being Workshop (last date):_______________________________________

Insurance Carrier (please attach a copy of insurance card)____________________________________

Physician’s Name:_____________________________ Phone: __________________________________

Person to contact in case of emergency should parents not be available:____________________________

Telephone numbers:_____________________________________________________________________

Relationship to camper:___________________________________________________________________

School Attending:___________________________________________Grade Entering in Fall___________

Religious Affiliation:______________________________________________________________________

Height:_______________Weight:___________________T-Shirt Size:_______________

A reservation fee of $100 must accompany this application. This is credited toward the total fee. $50 of the reservation fee will be refunded in case of cancellation NOT LATER THAN March 31st.

I give Healing Forest Foundation and Kid Power Camp permission to use in its catalog, video, or on its website any camp picture in which the likeness of my son or daughter appears. Also, I hereby give permission to the physician selected by Kidz Power Kamp to hospitalize, secure proper treatment for, and to order injections, anesthesia and surgery as needed for my child names above. I have read and agree with the terms of enrollment as stated with this application.

Signed: (parent or guardian)_____________________________________________Date:____________

CONFIDENTIAL PARENT INFORMATION

1. Does your child want to come to camp?_______________________________________
2. Has he/she been a camper elsewhere?____When?_________Where?______________
3. Does you child have siblings?_______Please list Names & Ages below

Name_____________Age____ Name_____________Age____ Name_____________Age____ Name_____________Age____ Name_____________Age____ Name_____________Age____

4. Does your child meet people easily?____________________________________________
5. What is your child most looking forward to in her/his camping experience?______________

Camper Application

Name: ________________________________________

Name you like to be called: _________________________

Email address: __________________________________

I think that Kid Power Camp is ______________________

My favorite activities and hobbies are _________________

_______________________________________________

My favorite area in school is ________________________

NOT MAYBE TOTALLY Fun loving ڤ ڤ ڤ Smart ڤ ڤ ڤ Attractive ڤ ڤ ڤ Good Grades ڤ ڤ ڤ Shy ڤ ڤ ڤ Friendly ڤ ڤ ڤ Confident ڤ ڤ ڤ Communicative ڤ ڤ ڤ Active ڤ ڤ ڤ Trusting ڤ ڤ ڤ Coordinated ڤ ڤ ڤ Loving ڤ ڤ ڤ

Please rate yourself in the following categories

KIDZ POWER KAMP

HEALTH CERTIFICATE

Child’s Name _________________________________Date of Birth___/____/___

First Middle Last Mo. Day Yr.

Gender ڤڤ____ Male ____Female

Street Address _____________________________________________________

City_____________________State_________________Zip__________________

Parent’s Name______________________________________________________

Telephone (home)______________________(work)_______________________

Email address _______________________ (cell)_________________________

“I hereby give permission to Four Winds Peace Center and Kid Power Camp to secure emergency medical and surgical treatment and routine non-surgical medical care for my child while in camp (including aspirin, acetaminophen, ibuprofen, and prescription drugs.)”

Signed________________________________________Date________________

Other emergency name and phone # __________________________________

Insurance Company______________________Policy Number______________

Child’s Doctor’s Name____________________Doctor’s Phone #____________

Allergies he/she has_________________________________________________

Diseases he/she has had_____________________________________________

Other (e.g. epilepsy, asthma)__________________________________________

Medication presently being used_______________________________________

Special conditions:

Reactions to Drugs____________Sleepwalking___Bedwetting___Fainting___

Other____________________________________________________________