Fill out this form to register your camper...

Camper Name

Address

Town

State

Zip Code

Grade Completed

Age

Sex

male

female

School District Camper Attends

Church Camper Attends (in any)

Home Phone

Parent/Guardian Work Phone

Camp Registration for week of

CabinMates Request #1

Request #2

Health Report:
Emergency Contact Name		Relationship

Daytime Phone

Evening Phone

Doctor Name

Doctor Phone

Health conditions or special needs requiring medication, treatment or restrictions:

Please list any restrictions from activities:

Allergies: (drugs, food or other):

Medications currently taken:

Date of last tetanus booster:

I certify that I am the parent or guardian of this child and I hereby give my permission for my child to attend the camp session for which they are registering. In the event I cannot reached in an emergency, I authorize all hospital/medical treatment deemed necessary by the camp medical staff for the welfare of the child.

Yes

I give permission for my child’s name, address, and phone number to be shared with other campers in their group, or cabin.

Yes

I give permission for pictures of camp activities that include my child to be used for camp promotional purposes.

Yes

I understand the employees of HIS Thousand Hills have received extensive training, and will work to protect the emotional and physical safety of myself and/or my child. I understand that climbing, high ropes courses, low ropes courses, ground initiatives and other activities in the Challenge Adventure Program for which I and/or my child have enrolled, entails certain risks. I elect to participate in spite of these risks.
Therefore, for myself/my child, I knowingly and voluntarily assume all risks involved in my/my child’s participation, and do hereby release HIS Thousand Hills and its staff, volunteers, members, trustees, officers, independent contractors and agents from any all liability, damages, costs and expenses arising out of or relating to bodily or psychological injury, loss of life or personal property that may occur as a result of participating in this program.

Yes

I have insurance to cover any accidents sustained to my child as a result of his/her participation in any activities at His Thousand Hills. His Thousand Hills will in no way be liable for any accidents or injuries that may occur to my child, and is released from all responsibilities and obligations.

Yes