Registration Form

To register, your need to accomplish three things:

  1. Complete the Camper Application Form below.
  2. Either pay in-full or submit $95 to hold the spot in camp until 2 weeks before the camp session. Go to the Payment Page
  3. (Optional) Complete the Camper Scholarship Application
Camper Registration

CAMPER PERSONAL INFORMATION

City
State/Province
Zip/Postal

PARENT or GUARDIAN

City
State/Province
Zip/Postal

SECOND PARENT or GUARDIAN

City
State/Province
Zip/Postal

LEGAL CUSTODY

City
State/Province
Zip/Postal

FINANCIAL GUARANTOR

City
State/Province
Zip/Postal

EMERGENCY CONTACTS

Please list two emergency contacts who will be the best contacts during the camp day.
City
State/Province
Zip/Postal

City
State/Province
Zip/Postal

AUTHORIZATION TO TRANSPORT THE CAMPER

(Emergency contacts are considered persons authorized to transport the child. We must receive a note from your prior to the child being transported by someone other than parents/guardians and those with legal custody.)
(Appropriate paperwork, such as a court order or signed custody agreement, must be provided if a parent is not allowed to transport the child.)

HEALTH INFORMATION

MORE ABOUT YOUR CHILD

ADDITIONAL INFORMATION

Photo/Video Release

Camp Kum-Ba-Yah hereby requests permission to use photographs and/or video footage of the camper(s) named on this application for the purpose of program promotion. By checking "yes" and signing this application, the parent/legal guardian releases Camp Kum-Ba-Yah from all legal claims and/or fees while using the photographs and/or video footage for promoting its program.

EMERGENCY AUTHORIZATION

I, as parent or guardian of a camper, give permission to the medical or dental personnel selected by the Camp Director to order x-rays, routine tests and treatment for the camper. In the event I cannot be secured in an emergency, I hereby give permission to the physician or dentist selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper. In the event of a serious allergic reaction or condition requiring immediate attention on site, I authorize the Camp Director or personnel selected by the Camp Director to give the appropriate medication which can include but not be limited to, epi pen or benadryl. I further acknowledge I will be responsible for the payment of all charges related to the medical or dental services for the camper beyond the limits of the camp’s accident and/or liability insurance policy. This form may be photocopied for use outside of camp.If my child becomes ill during camp hours, I agree to pick up my child as soon as possible. Otherwise, the above “Emergency Authorization” applies.I further agree to report to Camp Kum-Ba-Yah within 24 hours if any member of the camper’s immediate household has developed any communicable disease as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.

PARENT/GUARDIAN AGREEMENT and AUTHORIZATION

I, as parent or guardian of a camper, understand Camp Kum-Ba-Yah takes reasonable precautions to insure the program and activities at Camp Kum-Ba-Yah are conducted by qualified personnel in a safe and responsible manner. However, I further understand these activities involve certain risks which include, but are not limited to, ropes course, water sports, food preparation over a campfire, and hiking. I, the undersigned, parent/guardian of a camper, individually and on behalf of the camper, recognize these risks and agree to assume these risks by attending or allowing the camper to attend Camp Kum-Ba-Yah and participate in these programs. I, as parent/guardian, individually and on behalf of the camper, hereby release, discharge, and agree to save-harmless and indemnify Camp Kum-Ba-Yah, its Director, Program Directors, Members of the Board, staff and volunteers from all liability for damage, injury, illness, or death to the camper or his/her property relating to or deriving from his/her presence at Camp Kum-Ba-Yah or participation in or travel to or from Camp Kum-Ba-Yah activities. I give permission for my child to be transported by Camp Kum-Ba-Yah to and from approved program activities and/or in case of emergency.I have read and understand the contents of this application, including the Emergency Authorization, the Refund and Cancellation Policy, the Payment Policy, and the Parent Agreement.

POLICIES AGREEMENT

CERTIFICATION

The person filling out this form certifies that the information provided is complete and correct. Please type in your name and sign the signature block below with your mouse or other means.