Family Medical Insurance

The information provided above is correct to the best of my knowledge, and the person herein described has permission to engage in all camp activities, except as noted. I have read the camp rules and agree that my child will abide by them. I hereby give my permission to the camp medical staff to secure proper treatment for the above child in case of injury or illness. 

WVCYC Application Form

Notify In Case Of Emergency

Medical Information

(Please Check All Pertinent Information Below)

 

Date:

A $5 Registration Fee must be sent in along with this form in order for a spot to be reserved.  The remaining $65 is to be paid on the first day of camp.  This fee completely covers the cost of room and board, crafts, meals, and all class materials.  Campers may bring additional spending money for the camp store which sells soda, candy, snacks, etc.  $5 store credit cards are sold on the first day of camp for this purpose.

Grade:

Disability or Chronic Disease:

Dietary Modifications:

Physician’s Name:

Physician’s Phone:

Use Internet Explorer to print the registration form. If you are still having trouble printing the entire form, please call Nick Deiger at (304) 534-5282 for a hard copy of the application. We apologize for any difficulties this has caused. We do need the entire application form for processing. Thank you!

____Tylenol     ____Benadryl     ____Tussin DM     ____Aspirin     ____Motrin     ____Pepto Bismol      ____Ibuprofen

____Aleve (Naproxen Sodium)       ____Sinus Tablets       ____Antacid/Tums       ____(Laxative (Exlax, Correctal

(Please Check Medication Dosage That Your Child May Receive If Needed)