Lylewood Christian Camp

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Lylewood Christian Camp

Christian Camp

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Camper Application

Please Choose your Camp Session
Selected Session - Cost of retreats is $55, Summer sessions are $165. Fees are turned in during Retreat/Camp registration or Pre-Paid online.*
Camper Name*
First Last
*
- Male
- Female
Camper Address*
Street Address Address Line 2 City State ZIP Code
Camper Home Phone
Birthday*
Date Format: MM slash DD slash YYYY
Age at Time of Camp*
Please enter a number from 4 to 20.
T-Shirt Size*
Is this your first time at Lylewood?*
- Yes
- No
Father/Male Guardian Information
Father/Male Guardian Name*
First Last
Father/Male Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father/Male Guardian Phone #*
Father/Male Guardian Email*
Does camper live with this person (Father/Male Guardian)?*
- Yes
- No
Mother/Female Guardian Information
Mother/Female Guardian Name*
First Last
Mother/Female Guardian address same as Father/Male Guardian?*
- Yes
- No
Mother/Female Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother/Female Guardian Phone #*
Mother/Female Guardian Email*
Does camper live with this person (Mother/Female Guardian)?*
- Yes
- No
Emergency Contact (other than parent)
Emergency Contact Name*
Relationship to Camper
Emergency Contact Primary Phone*
Pick-Up Authorization/Custody Restrictions
Please list authorized persons to pick up your child, other than parents
Medical & Emotional Health Information
This applicant has seen or is currently seeing a professional to address mental/emotional health concerns.*
- Yes
- No
Please state the management plans being followed:
Allergies
Medication Allergies -- List all known. Describe reactions and treatment for the reactions.
Food Allergies
Other Allergies -- Include insect stings, hay fever, mold, asthma, etc.
Medical Information
Does the Camper take ANY medications, both prescription and/or over-the-counter? If yes, all medication must be in original container with camper's name and dosing information. All medications will be administered by camp personnel.*
- Yes
- No
Medication #1
Medication #1 Dosage
Medication #1 to be taken at:
- Breakfast
- Lunch
- Supper
- Bedtime
- As needed
Reason for taking Medication #1
Add a second medication?
- Yes
- No
Medication #2
Medication #2 Dosage
Medication #2 to be taken at:
- Breakfast
- Lunch
- Supper
- Bedtime
- As Needed
Reason for taking Medication #2
Add a third medication?
- Yes
- No
Medication #3
Medication #3 Dosage
Medication #3 to be taken at:
- Breakfast
- Lunch
- Supper
- Bedtime
- As Needed
Reason for taking Medication #3
I hereby authorize the Camp Nurse to administer the following (check all that apply):
- Tylenol / Acetaminophen
- Motrin / Ibuprofen
- Benadryl
- Pepto Bismol
Please note that the dosage administered will be the same as the on specified on the medication.
Minimal first aid is provided by camp staff. A general list of the topical treatments used at the camp is provided below. Check any which you will allow to be used for your child as a first aid treatment.
- Neosporine
- Rubbing Alcohol
- Hydrogen Peroxide
- Calomine Lotion
- Bactine
- Aloe Vera
Note, the generic or store brand equivalent may also be used.
List any restrictions to activity or any medical conditions not previously indicated.
Insurance Information
Is the camper covered by medical insurance?*
- Yes, the camper is covered by medical insurance
- No, the camper is not covered by medical insurance
A camper must be covered by medical/health insurance or must submit an insurance release/parental agreement to cover any medical expenses in order to attend camp.
Policy Holder Name, Address, City, State, Zip
Policy Holder Date of Birth
Date Format: MM slash DD slash YYYY
Relationship to Camper
Policy Holder Occupation
Policy Holder's Employer Name, Address, City, State, Zip
Insurance Company Name, Address, City, State, Zip
Policy Number
Plan / Group Number
I/We agree and hereby give my/our permission for the minor child to receive medical treatment at such times and by such medical professionals and/or health care facilities as Lylewood Christian Camp staff shall deem appropriate. I/We hereby agree to be financially responsible for any and all treatments secured for the benefit of the minor child. Further, I/we understand that no insurance information has been forwarded concerning the designated camper and that all invoices that result from medical treatment, of any type or kind, will by my/our personal responsibility. I/we agree that the type and level of medical treatment shall be in the sole discretion of Lylewood Christian Camp staff and I/we hereby agree that such treatment is reasonable and in the best interest of the child, and agree to the payment of such treatment.

I/We agree that in the event I/we fail to pay said invoices, I/we will pay all court costs and plaintiff's attorney fees that arise as a result of the collection of that cause.

IN WITNESS WHEREOF I have hereunto set my hand on the date written below.
Name of Parent or Legal Guardian*
I hereby give permission for my child to participate in all activities of the camp program, unless otherwise specified in writing. I certify that my child is amenable to discipline and is free from habits that would make him/her an undesirable camper. I understand that I am responsible for all medical expenses. I have read the information and policies about Lylewood Christian Camp and will follow and support each of these. I also give permission for my child’s picture to appear in camp information including the camp web site.
Name of Second Parent or Legal Guardian (optional)
Date*
Date Format: MM slash DD slash YYYY
Lylewood Updates?
- I'd like to receive e-mail newsletter about Lylewood
- You may text message me for important communications about my camper or camp.

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Non-Profit Statement

Lylewood Christian Camp is a non-profit organization.

Mission Statement

In an effort to maintain the dream of Arch and Edwina Lyle, the purpose of Lylewood Christian Camp is to provide a safe, nurturing environment that allows for spiritual growth and the building of eternal relationships. In view of this purpose, the mission of the leadership of Lylewood Christian Camp is to utilize our God-givenn resources to the best of our ability to improve and maintain the facilities of the camp to better fulfill the purpose of why we exist.

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Lylewood Christian Camp, 2017

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