2008
Luther Park Camping & Retreat Center
CAMPER REGISTRATION AND HEALTH FORM Print out
by clicking file on your browser and select print.Mail or fax to Luther
Park; must be signed by parent/guardian.
A $150 deposit is required for registration.
Mail
to: Luther
Park Camping & Retreat Center
30376 Lakes Drive, Danbury, WI 54830-3013
Fax
# (715) 656-3013
Camper Name __________________________________________________________
Grade Completed________Age_____Sex_____Birth Date________________________
Camp Date: First Choice_________________________________________________
Name of one cabinmate___________________________________________________
Date for 1/2 off 2nd Week_________________________________________________
Name of one cabinmate___________________________________________________
Registering for:
Cabin
Tree House
Canoe
Music Camp: high voice/low voice (circle one)
Double Week
Leadership Training
Leadership Mentoring
TIM Team
Family Camp
Grandparent/Grandchild Weekend
Great Lakes Mission Trip
Congregation_________________________________City____________________________
Amount paid by church________________
Transportation: (check one) I
will:
provide my own transportation
need transportation to and/or from camp (available only for the weeks
of June 8-13, July 13-18, July 20-25, and August3-8)
($60 round trip/$40 one way: non-refundable) I will be riding the bus:
(check one)
round trip
one-way. If one way, which way:______________________________
Choose a pick up location:
Elim Lutheran, 3978 W. Broadway, Robbinsdale
House of Prayer, 7625 Chicago Ave. S., Richfield
Method of Payment:
Check/money order. Make payable to Luther Park.
VISA
MASTERCARD
DISCOVER Credit Card
Acc’t. # ___________________________________________
Expir. Date _________________________________________
Signature __________________________________________
Total Amount $ ______________________________________
In addition to the camp fee, I wish to help support the Campership Program.
Enclosed is my donation of $ _______________________
Custodial Parent(s)/Guardians ____________________________________________
Address_________________________________________________________________
City___________________________________________State________Zip__________
Phone: Work _________________ Home ______________________________________
E-mail: _________________________________________________________________
Second Parent(s)/Guardians__________________________________________________
Social Security #___________________________________________________________
Address___________________________________________________________________
City___________________________________________State________Zip____________
Phone: Work _________________ Home _______________________________________
E-mail: ___________________________________________________________________
Allergies:
Insect stings
Poison Ivy
Hay Fever
Penicillin
Other Drugs:______________________
Other:____________________________
Medications:
_____ This person takes NO medications on a routine basis.
_____ This person takes the following medications:_______________________________
_________________________________________________________________________
_________________________________________________________________________ (Luther Park administers medications only according
to prescription label)
My child has permission to engage in all camp activities,
except as noted by myself and the examining physician. In the event I
cannot be reached in an emergency, I hereby give permission to the physician
selected by the camp director to hospitalize, secure proper treatment
for, to order injection, anesthesia or surgery for my child as named below.
I voluntarily waive any claim against the sponsoring institution, local
churches and camp personnel for any mishap or lost articles, or any and
all causes which may arise in connection with activities of the above
organization. I understand that unless I provide separate written notice,
photos taken of my child at camp may be used for camp-approved publications
such as the Luther Park Echoes.
My child and I have read the Luther Park Code of
Conduct and agree to follow it. Inability to follow the Code of
Conduct gives Luther Park the right to send the camper home without
refund at the expense of the camper's parent/guardian.