Number of campers registering per family
Name 1 DOB (MM/DD/YYYY) Age: F:
Name 2 DOB (MM/DD/YYYY) Age: F:
Name 3 DOB (MM/DD/YYYY) Age: F:
Name 4 DOB (MM/DD/YYYY) Age: F:
Address: City: State: Zip Code:
Parent/Guardian Work/Cell Phone:
St. Mark is a Serbian Orthodox Camp conducted in accordance with the teachings of the Serbian Orthodox Church.
Camper is Baptized in the Orthodox faith?
Church Affiliation: Parish Priest Name:
Primary Contact: Emergency Phone: Relation to camper:
Secondary Contact: Emergency Phone: Relation to camper:
Physician’s Name: Business Phone:
Date of last physical exam:
Dentist’s Name: Business Phone:
Do you carry family medical/hospital insurance? Please provide carrier and policy number:
Will camper be taking medication while at camp?
(If yes, please specify child if registering more than one, medication, dosage, what time and reason for taking. All medication MUST be checked into staff)
Permission to dispense medicine if needed:
Acetaminophen (non-aspirin compound, i.e., Tylenol) can be given for a temperature above 100 degrees, earache, and headache.
Benadryl can be applied for insect bites, rashes, and or itching.
Please list out any allergies child may have and describe reaction and treatment. (ex. penicillin, insect stings, poison ivy, hay fever, food, other)
(Specify name of child if registering more than one)
Does the camper have a history or is prone to any of the following: Asthma, homesickness, frequent ear infections, seizures or convulsions, dizziness during or after exercise, heart disease, hyertension, bleeding/clotting, diabetes, chicken pox, measles, frequent headaches, diarrhea or constipation, stomachaches
(Specify name of child if registering more than one):
My child has permission to engage in all prescribed camp activities except as noted. The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication and activity limitations which should be known to the camp staff and medical personnel. I am aware of and accept the risk inherent in the program activity. I give consent in advance for medical treatment at an appropriate facility in case of illness or injury.
Parent/Guardian Signature - By placing initials in this box you agree to provide authorization for treatment.
PARENTAL CONSENT: In the event that my child becomes ill or sustains an injury while in the care of the St. Mark’s Camp in Sheffield Village, Ohio, I, the undersigned parent or guardian, grant authority to the Camp Clergy or Camp Staff Member, to act on my behalf in obtaining any medical treatment that may be necessary. In the event of an accident or medical need, I will be responsible for all medical or other expenses and will not hold responsible St. Mark’s Camp, the Serbian Orthodox Eastern Region Diocese of America, or The Diocesan Kolo of Serbian Sisters. I hereby give permission for my child to take field trips while attending St. Mark’s Camp in Sheffield Village, Ohio. I also accept financial responsibility for any damages caused by my child during his/her stay at St. Mark’s Camp.
CAMP DISMISSAL: Any camper wearing clothing deemed inappropriate by the Camp Clergy or Camp Staff Member will be refused participation in camp activities until properly dressed. ANY BEHAVIOR UNBECOMING A CAMPER WILL RESULT IN IMMEDIATE DISMISSAL.
SPENDING MONEY: Spending money for personal purchases of snacks during camp outings is extra. All campers are responsible for their own spending money. St. Marks Camp is not responsible for lost or stolen money.
Your full cooperation and understanding of camp rules and regulations will result in a happy camp experience.
Parent/Guardian Signature - By placing initials in this box you agree to the above statement