Camp Anavah Registration Camper Registration And Health Form Please fill out both the registration and health form completely. Name *Gender *Please select an optionMaleFemaleBirthdate *Grade Entering *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePhone *Email Address *ChurchPlease check the dates you plan to attend *Jr Camp Week 1: Wonder Junction: July 14th-July 18thJr. Camp week 2: Sontreasure Island: July 21st-July 25thTeen Camp Week 1: Pirates of Anavah: July 28th-Aug 1stTeen Camp Week 2: Food Network: Aug 4th-Aug 8thJr. Camp week 3: Kingdom Chronicles: Aug 11th-Aug 15thJr. Camp week 4: Sonquest Rainforest: Aug 18th – Aug 22ndCamp Costs $65 Per WeekTotal = $Payment is due by the first day of each week.Consent *Please select an optionYes, I give permission for camper to swim at Glimmerglass state park.No, I do not give permission for camper to swim at Glimmerglass state park.Select this box If you are only attending Teen CampConsent *Please select an optionYes, I give permission for Camp Anavah to take pictures of my child to use for promotional purposes.No, I do not give permission for Camp Anavah to take pictures of my child to use for promotional purposes.Information To NoteLunches are now available for those who want a lunch. Please bring immunization records for your child, this must be brought on the first day of camp. Make checks payable to Camp Anavah and mail to: Camp Anavah P.O Box 248 West Winfeild, NY 13491HEALTH FORM1st Emergency Contact:Name *Phone *Relation to camper *2nd Emergency Contact:Name *Phone *Relation to camper *3rd Emergency Contact:NamePhoneRelation to camper*Campers must have current shot records on fileIn case of emergency, I understand every effort will be made to contact me, however, if I can not be reached, I give permission to the physician selected by the Camp Director, to secure proper medical treatment for my child.Signature *Parent or legal guardian's digital signature.Medical Questionnaire for Registration1.Does your child wear contacts? *Please select an optionYesNo2. Does your child have any allergies to medications? *Please select an optionYesNoInput3. Does your child have any allergies to food products? *Please select an optionYesNoInput4. Does your child have any allergies to environmental elements like insect bites? *Please select an optionYesNoInput5. Does your child have any special needs we should know to accommodate their stay with us? *Please select an optionYesNoInputSignature *I have carefully read this form completely. I acknowledge that by checking this box it is the equivalent to my digital signature. Register NowPlease do not fill in this field.
