Registration Form

Camper’s Full Name _________________________ Date of Birth ____________
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Getting Ready for Camp Smoky and General Information
(Please keep PAGE ONE for your info)
Valuables: Campers are not to bring non-essential items to camp. The camp does not assume responsibility for lost
articles. Label all valuables, luggage, clothing, and other items for identification. Put pillows, blankets, or sleeping
bags in plastic bags and label. Include extra plastic bags for the return trip.
What to Bring
Bible
Swim suit or trunks
6-8 pairs of socks
Jacket or sweatshirt
Long Pants
Towels & wash cloths
Pillow & bedding for twin bunk OR sleeping
bags
Change of clothing for each day of the week
(shorts are allowed)
Sweatshirt/Fleece (at least one)
Pajamas
Underwear
2 pairs of tennis shoes
Toothbrush and toothpaste
Soap
Shampoo
Labeled laundry bag
Flip flops for shower
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Optional
Pump spray insect repellent
Sunscreen
Flashlight
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What not to Bring
X Radios X Fireworks X Cell Phones
X Matches X Sheath Knives X Computer equipment
X Candy X Tobacco Products X Snack Food or drinks
X Handheld Media Devices (Nintendo DS/ PSP/ I-Pod/ Etc….)
X MONEY
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Mail
Campers love mail! The easiest way is to bring it with you on check-in
day. You can also send it by snail mail and address it the following
way:
Camper’s Name
3311 Camp Smoky Lane
Sevierville, TN 37876
A nurse is on duty 24 hours a day to provide prompt medical
treatment for minor injuries. If a physician is needed, the
services of the LeConte Medical Center will be used and the
parent will be contacted. All medications must be in original
bottles/containers.
Behavior that all campers should abide by: Treat others as you would like to be
treated and have the same attitude as Jesus!! Campers are expected to behave in
a manner consistent with the camp’s goals of providing a safe, positive, and
respectful Christian community. While counselors will work with campers to handle minor disciplinary problems, the camp does
reserve the right to send any camper home whose behavior is consistently inappropriate. Any direct threat or actual physical harm to
one’s self or others will result in a camper being sent home immediately.
Clothing
As a Christian camp we expect clothing to be modest and to not be offensive or make others feel uncomfortable. Clothing also needs to be safe
for wear in our active program. Items that are inappropriate include:
- Clothing that contains alcohol, tobacco or drug related logos or graphics
- Halter tops, tube tops or shirts with exposed backs
- Clothing that is sheer and can be seen through
- Short skirts or mini-skirts
- Exposed midriffs
- Exposed underwear
- No two piece suits for girls (one piece suits only)
- Dangling chains from pockets, wallets, etc.
- Spiked bracelets and collars
Meals:
Campers will be served three balanced meals daily. Two snacks per day are included in the price of each camp.
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Camper’s Full Name _________________________ Date of Birth ____________
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All medications brought to camp, both prescription and non-prescription, must be in the original containers and clearly
labeled with camper’s name. All prescription medications will be dispensed according to physician’s instructions.
Medications
All! medications brought to camp, both prescription and non-prescription, must be in the
! containers and clearly labeled with camper’s name. All prescription medications
original
! be dispensed according to physician’s instructions.
will
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Pre
Prescription and Routine Medications – Please list all medications brought by camper to be taken
regularly throughout the camp week listing exact dosage and dispensing orders prescribed by your doctor.
Medications must be in original containers.
Medication
Dosage
Times Taken (Breakfast, Lunch, Supper, Bed, Other)
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Parent/Guardian Signature verifying instructions: __________________________Date__________
If
If dispensing orders differ from original container’s label,
a Physician’s signature is required: ________________________________Date________
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If your child has a need to see our camp nurse, we request your permission to administer
over-the-counter Medication. We will give the recommended dosage indicated by the
manufacturer.
Here is a list of the medications we have at camp. Weight of your child for medicine
dosing accuracy! _________
Children's Tylenol
Adhesive Bandages
Pepto Bismol
Tylenol
Rubbing Alcohol
Hydrocortisone Cream
Ibuprofen
Cough Drops
Ammonium
Neosporin
Hydrogen Peroxide
Benadryl (If your child gets a bee sting)
Ivy Rest or Calamine Lotion for poison ivy or oak
Sting-kill external anesthetic disposable swabs with Benzocaine
Please indicate anything that you do NOT want the camp nurse to give your child.
________________________________________________________________________________
All information on page two and three on the medication and emergency
information is correct.
Parent's Signature_________________________Date _____________
Notary Sign and Seal __________________*can
be notarized at camp
registration table for free!
Please bring this page of the Health Form with you to camp on opening day.
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Registration & Camper Health Form for Camp Smoky
Circle the date of camp: Children/June 26 - 30; Youth/July 17 - 22
Camper Name: __________________________ Age: _____ Sex: ____ Birthday: ____________
Camper’s
Full Name
ofAS
Birth
____________
Completed Grade
in School_________________________
_________ T-shirt size (CIRCLE ONE) YSDate
YM YL
AM AL
AXL
Address: __________________________________
City: ______________ State: _________ Zip: ____________
Parent/Guardian: _______________________________________ C
Child lives with: Mom Dad Both Other ___________ Custody Issues Yes No
E-mail: _____________________________________
Home Phone: (________)-_______________Work: (________)-______________
Mom Cell: (_________)-_________________ Dad Cell: (_________)-_________________
Camper’s Physician __________________ Phone #___________________
Family Insurance Company ______________________________
Insurance Subscriber’s Name ______________________ SS#_______________
Ins Insurance Claims Address _______________________
Pre-Authorization Phone # if required ( ) ____________
Emergency Contact:
Name of person to notify (other than parent): ______________________________________
Phone: (_________)-___________________ Address:
________________________________________________
City: ______________ State: ___________ Zip: ______________
Name of Church: ______________________________________ Pastor:
__________________________________
If your church will be paying a portion of the tuition, you must fill out this section, and a church representative
must sign it. ______________________
If church is paying part or all of your camper fee please give the name of a contact
person:_______________________
Amount being paid by church: __________________Phone of contact person: (_________)-________________
Is child subject to: (Circle all that apply)
Diabetes
Frequent colds Asthma Bronchitis
Ivy
Nosebleed
Abscessed ears Fainting
Bee Sting Allergy
Oak
Earache
Stomach upsets Sore throat
Bed-wetting
Sumac
Headache
Sleepwalking
Sinusitis
List communicable skin eruptions or disease:
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Emergency Treatment, Activities, and Photo Release Permission
This health information and history is correct to my knowledge and the above named child has permission to engage in all prescribed
camp activities except as noted by me. If I cannot be reached in an emergency, I hereby give permission to the physician selected by
the Camp Smoky Directors and Nurse to secure proper treatment for, hospitalize and to order injections, anesthesia, or surgery for
the above named child. I understand that I am responsible for expenses incurred by sickness or injury not covered by camp insurance.
I understand that children may be photographed or filmed while participating in camping activities and that these photographs or film
may be used in print or in other media to promote Camp Smoky. I give permission and consent and allow photographs to be taken during
camp session activities. I further give permission and consent that any such photographs may be published and used by Camp Smoky and
the Sevier Baptist Association, to illustrate and promote the camp experience, Camp Smoky and its camp programs.
Parent/Guardian ___________________________________ Date__________________
Has camper ever had an allergic reaction to: (describe what sets off reaction and its severity)
Foods: ___________(Please list) ________________________________________________________
Drugs: __________ (Please list) ________________________________________________________
Insect Stings: ________ Has camper ever been stung by a bee? __________
Does camper carry an Epi-pen? _________ **If yes, please make sure and bring to camp and list on medication form!
Ivy Poisoning:________________________Other: _______________________________________
Camper Profile (Please circle)
Physical Condition: Excellent
Good
Fair
Poor
Temperament: Timid
Quiet
Sensitive
Average
Excitable
Aggressive
Other
Adjusts to contemporaries: Very Easily
Easily
With Difficulty
Participates in group activities: Easily
With Encouragement
Only When Encouraged
Known Fears or Weakness: _________________________________________________
Eating, Sleeping Habits: ____________________________________________________
Any Activity restrictions: ____________________________________________________
Special dietary concerns:____________________________________________________
PLEASE MAIL THIS PAGE WITH YOUR PAYMENT AND WITH SCHOLARSHIP REQUEST LETTER FROM YOUR
PASTOR IF ONE IS BEING REQUESTED. MAIL TO SEVIER COUNTY ASSOCIATION OF BAPTISTS, P.O. BOX 4099,
SEVIERVILLE, TN 37864.
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