Camp Millican Registration 2018 (I)

Camper Information
Camper's Legal Name*

First NameLast Name
Camper's Preferred Name

First NameLast Name
Camper's Date of Birth

MonthDayYear
Date
Age of Camper During Camp Session*
Camper's Shirt Size*
Please note, the primary contact is the default emergancy contact. In all cases staff is instructed to call/email contacts in the order they are listed on this form.
Parent/Guardian's Name*

First NameLast Name
Primary/Emergency Contact Relationship with Camper *
Primary/Emergency Contact E-mail*
Primary/Emergency Contact Phone Number*

Area CodePhone Number
Does your child have a medical condition, severe allergies or physical limitations that will require special treatment or consideration while at Camp Millican (Further details can be listed below)*

YesNo

Secondary Emergency Name*

First NameLast Name
Secondary Phone Number*

Area CodePhone Number
Please use the space below to list any additional persons who may be picking up your child during camp. Please use this space to list details and phone number. (Note: Camp Millican staff is requires to check ID's before releasing a camper into the care of anyone other then a designated guardian.)
Camper's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

	Yes	No
Been hospitalized in the last 12 months
Have a recurrent/chronic illness
Had a recent infectious disease
Had a recent injury
Has asthma/wheezing or shortness of breath
Have Diabetes
Has a sensitivity to the heat/sun
Had seizures
Has frequent headaches/migraines
Had dizziness/fainting
Passed out/had chest pain during exercise
Had mononucleosis ("mono") during the past 12 months
Ever had back or joint pain
Have skin problems
Has traveled outside of the country in the past 9 months
Has had lice in the past 3 months

	Yes	No
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months, seen a professional to address mental/emotional health concerns?
Had issues with sleep?
Had a significant life event that continues to affect the camper's life? (History of abuse, death of a loved one, adoption, foster care, divorce, new sibling, other)

	Yes	No
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Antihistamine/allergy medication
Diphenhydramine antihistamine/allergy medication
Generic Cough drops
Sore throat spray
Eye drops
Ear drops
Anti-itch cream (Cortizone)

	Yes	No	Apply only the product provided by parent
Sun Screen
Aloe
Bug Spray
Calamine Lotion
(natural) Bug bite soothing cream
Lip balm
Essential oils like citronella & lavender
Shaving Cream (for games)
Anti-bacterial cream (neosporin)

Camp Millican Registration 2019

Sponsor a Camper Scholarship	Sponsor a camper Scholarship Fund	Price
Single-child Scholarship		$275.00
Sibling Scholarship		$550.00
Family Scholarship		$1,000.00
1/2 Scholarship		$137.50
Other		$50.00

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