Camp Joy
Camp Joy 2010
June 20-26th
Ages 7-14
Child’s Name ___________________________________________ Age _______ Gender: M__ F__
Child’s Birth date_________ Names of Parents ___________________________________________
Home Address __________________________ City ______________ CA, Zip Code ____________
Home Phone# (___)_____________ Work # (___)______________ Cell # (____)________________
Emergency Contact (other than parents): Name _________________ Relationship to child ___________
City ___________________ Home # (___)________________ Other # (____)__________________
_________________________________________________________________________________
Health Insurance and Health Information of the child:
Insurance Company _____________________________________ Policy # ___________________
Is your child allergic to any types of medicine? Yes____ No____
If yes, please specify _______________________________________________________________
Is your child allergic to any types of food or plants? Yes ____No____
If yes, please specify _______________________________________________________________
Does your child have any type of disease? Yes ____No____
If yes, please specify _______________________________________________________________
Does your child have a restricted food diet? Yes ___ No____
If yes, please specify (you may attach a list to this application) _________________________________________________________________________________
If your child gets a headache or a stomachache, what medicine should be given (Advil, Tylenol, etc.)
_________________________________________________________________________________
Did your child have any type of surgery in the past year? Yes ____ No ____
If yes, please specify what type and when? ______________________________________________
Has your child broken any bones in the past? Yes ____ No ____
If yes, please specify __________________________________________ mo/yr ________________
(Please attach any additional times of injuries with broken bones and surgeries if applicable).
Will your child be able to play all sports and engage in physical activities at camp? Yes ____No____
If no, please specify which physical activities are not allowed and attach a list to this application.
What else do we need to know about the health of your child? ____________________________
_________________________________________________________________________________
I have given the correct information regarding my child’s personal information and health history.
Signature of Parent or Legal Guardian: _________________________________Date: _________
Medical Consent Form
Evangelical Christian Church
I hereby authorize the participation of (child’s full name) ________________________________ in activities of the Evangelical Christian Church. In consideration of the Evangelical Christian Church providing these activities, I on behalf of myself and other parents and guardians of the minor, do hereby release the Evangelical Christian Church and its staff from all claims and causes of action by reason of any injury which may be sustained as a result of these church activities, whether on the church premises or on the way to or from these activities. I agree to direct my child to cooperate and to conform to directions and instructions of personnel of the organization in charge of these activities. Should my child not do so, and should those leading an activity believe it necessary, I will come and remove my child from the activity as soon as possible after being called by a staff representative for that purpose. I understand and agree to leadership having access to my child’s room at all times.
I hereby give my permission to the physician, nurse, or dentist selected by the Evangelical Christian Church to secure medical or dental aid as required for illness or injury under a physician’s orders, including transportation to and from the necessary facilities. As a participant, I understand
that the Evangelical Christian Church is not obligated to carry any insurance to cover those medical and/or dental expenses. I understand that my personal insurance is my primary coverage.
Signature of Parent or Legal Guardian: ___________________________________Date: _________
____________________________________________________________________________________
Regular Price:
$200 per child! – If applications and checks are turned in or postmarked by June 6th, 2010.
( Special Discounts for Bigger Families: Frist two children pay full price.* 3rd, 4th, 5th, and etc… go Free.*
*Late fee of $20 after June 6th still applies.
Late Applications:
$220 per child! - If applications and checks are turned in or postmarked after June 6th, 2010
or on the first day of camp (June 20th, 2010)!
Make checks payable to Evangelical Christian Church & add Camp Joy 2010 on the Memo Line.
Please send your child’s application and payment (checks only) to the Address:
Camp Joy 2010 Attn: Nadia Shevchuk, Camp Director 116 W. Francis St., Corona, CA 92882
For more information: please call Nadia Shevchuk at (951)283-5379
or go to websites: and
Note: Children will be placed in groups according to their ages. We want all children to have an opportunity to make new friendships at Camp Joy. There will be no changes made regarding placements of children in their groups at the registration. Parents may make requests about special placement of no more than 3 children in one group and no later than June 10th!
( We are looking forward to see your child at Camp Joy: June 20th – 26th, 2010 (
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