• First Name
• Last Name
• Email Address
• Phone Number
• Street/PO Address
• City
• State
• Postal/Zip Code
• Age Select One
  6
  7
  8
  9
  10
  11
  12
  13
  
• Birthday
• Sex Male Female
• School
• Grade (Fall 2013)
• T-Shirt Size Select One
  Youth Small
  Youth Large
  Small
  Medium
  Large
  X-Large
  XX-Large
  
• Camper's Swimming Ability Select One
  Beginner
  Intermediate
  Advanced
  
• Does camper wear glasses/contacts? Yes No
• Children may make new friends at camp. May we release your phone number to other camper's families upon request? Yes No
• Would you be interested in a group photo? Yes No
• Parent/Guadian Name(s)
• Phone Number(s)
• Special notes for contact in case of emergency
• Emergency Contact Name
• Relationship to Camper
• Emergency Contact Phone Number
• Insurance Carrier
• Group Number
• Pediatrician's Name
• Pediatrician's Phone Number
• Indicate any of these diseases your child had. Bronchitis Chronic Car Infections German Measles Rheumatic Fever Whooping Cough Mononucleosis Hepatitis Chicken Pox Measles Strep Throat Mumps Pneumonia
• Can we give Tylenol, Benadryl, Ibuprofen, “over the counter” cough or allergy medicaion? Yes No
• Is the camper up to date on his/her immunizations? Yes No
• Has the camper been diagnosed with hyperactivity? Yes No
• Has the camper been diagnosed with ADHD? Yes No
• Does your child have asthma? Yes No
• If so, is an inhaler used? Yes No
• List any health problems or activity restrictions:
• List any drug allergies or allergic reactions:
• List prescription medications:
• Please list any allergies your child may have:
• Other serious illness:
• Other serious injuries:
• Operation/Surgery (please be specific):
• Does medication need to be administered during the camp day?
• Is there anything else we should know about your child’s health?
• Do you want any camp activities omitted? Yes No
• Any special problems or limitations? Yes No
• Any convulsions, concussions, or loss of consciousness? Yes No
• Any recent traumatic events or family changes? Yes No
• Any problems with social or motor skills? Yes No
• If yes to any of the above questions, please explain:


• Camp Fun-Plex is owned and operated by Karts Inc. DBA Fun-Plex. Scorz Sports Center is owned and operated by DEA Anderson Inc. Camp Fun-Plex and related organization may use pictures of my child in their promotional materials, including both printed and electronic media. My child has permission to engage in all camp activities except as noted. ASSUMPTIONS OF RISK AND RELEASE OF LIABILITY: In consideration of the named campers being permitted to participate in Camp Fun-Plex activities, we, the parents or legal guardians of the camper, on our own behalf and on the behalf of the camper (herein after 'Releasors'), herby acknowledge and agree that we understand and fully appreciate the risk of injury involved to the camper in participating in camp activities. The Releasors nevertheless hereby release, waive, and discharge Camp Fun-Plex, its officers, employees, agents, counselors, representatives, and premises owners and operators where camp activities take place (hereinafter 'Releasees') from all liability to the Releasors for any loss or damage, and any claims or demands on account of injury to the camper caused in any way in any of Camp Fun-Plex's camp activities. The Releasors hereby agree to indemnify and hold harmless the Releasees, and each of them for any loss, liability, damage, or costs and expenses including attorney fees they incur due to the camper's participation. It is the express intention of the Releasors to exempt and relieve the Releasees from any liability for personal injury, property damage, or wrongful death caused by the Releasee's own negligence related in any way to the participation of the camper in Camp Fun-Plex's activities. The undersigned acknowledges that he or she is fully aware of the legal consequences of accepting these terms containing the express waiver and release of liability. The health information on this registration form is accurate to the best of my knowledge. In an emergency, Camp Fun-Plex has my permission to obtain medical treatment for my child, including routine tests, X-rays, hospitalization, injections, anesthesia, or surgery.
• I have read and agree to the Terms and Conditions  

REGISTRATION FEES

Tuition fees are required. Select the lunch option if you would like Fun-Plex to provide lunch. Alternatively you may send a sack lunch at no charge. You may also choose to add an additional camp t-shirt if you would like an extra one.

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