Register

This electronic registration will temporarily reserve your child's spot at CHC, You will need to print a copy of this form, sign it, and mail it to the camp with your deposit in order to secure a place. We are required to have a hard copy and hand signature for each child. Thank You!!
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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