Register

Below is the form that you can use to register for all of the camps we provide. You can also download a copy and send it to us by mail.
On-line registration will only temporarily secure your spot for camp. We must have a printed copy of the registration page SIGNED by the parent / guardian sent to CHC with your non-refundable deposit. When the signed registration and deposit are received we will notify you of your reserved spot at CHC.

Personal Info --All info is required in this section

First Name:
Last Name:
Age:	Grade in Fall:
Gender:	Male Female
Address:

City:
State:
Zip:
Phone:
Email:
Emergency Number:
Emergency Contact:

Are you involved in a local church? Yes No

If yes, which church?

Would you be interested in participating in a Bible Study group? Yes No

Are there any allergies or special needs that your child has? i.e. Bee Sting; Bed wetting; Sleep Walking; Food Allergies:

Please GIVE THE DATES when each of the following were taken:[ The NYS Dept of Health will not allow us to accept a child without proper records. A copy of your school records should be sufficient as long as the dates are clear. ]

Please ensure that the dates are correct!
Tetanus :
Measles :
Mumps :
Diphtheria :
Rubella :
Polio :
Whooping Cough :
Hepatitus B :
Chicken Pox :
Haemphilius Influenza Type B :
Others:

Family Doctor:
Policy Number:
Name on the policy:

I permit my child to participate in all sports, hiking, and other camp activities. I certify that my child has had a physical exam within the last 12 months [ we recommend a fairly recent one ] by a physician and is physically able to do all activities with the exception of:

In the event of an emergency, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child.
Yes No
- a hand signature will be required upon arrival

Week chosen:
1st choice -
2nd choice -

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