- Camp Luther

CAMP LUTHER
1889 Koubenec Road Three Lakes, WI 54562
Phone (715) 546-3647 ¨ (877) 264-CAMP
EMERGENCY/MEDICAL INFORMATION FORM
Can be submitted anytime; but no later than JUNE 1st
This form is now included in our online registration process. If you filled out the Medical Form in your online registration, you do
not need to fill out this form.
Please do not fax; we will accept scanned & emailed forms to [email protected].
Remember: The more information the better! We want to be best prepared!
Camper Information:
Camper Name: FIRST
MIDDLE
LAST
Camper Home Address: STREET ADDRESS
CITY
Camper County of Residence:
Home Phone:(
Birth date:
/
/
Sex:
STATE
ZIP
)
Age:
This form must be completed and submitted to the Camp Luther office on or before June 1st. Failure to properly complete and submit this form
may result in the non-acceptance of the child/youth into the camp program. This form should be returned via USPS mail or scanned and emailed
with signatures. Do not fax!
Emergency Contact Information:
Parent/Guardian with legal custody to be contacted in case of illness or injury:
Parent/Guardian Name:
Relationship to Camper:
Home Address: STREET ADDRESS
CITY
Phone:(
)
Work Phone:(
STATE
ZIP
STATE
ZIP
)
Second Parent/Guardian or other Emergency Contact:
Name:
Relationship to Camper:
Home Address: STREET ADDRESS
CITY
Phone:(
)
Work Phone:(
)
Medical Insurance Information:
Insurance Company:
Insurance Company Phone:(
Policy Number:
Group Number:
Subscriber Name:
Date of Birth:
)
PCN (Medications) Number if Available:
Medications: Medications need to be followed as instructed on the bottle, if there is a change, please attach a physician note
Please list all medications brought to camp:
Name of Medication
Dosage
Health History:
Primary Physician Name:
Is the camper allergic to?
Bee Stings
Yes
Dairy
Yes
Penicillin
Yes
Times Given
Reason for Medication
Prescribing Physician
Phone Number:
No
No
No
Food (gluten, nuts, etc.)
Poison Ivy / Oak
Other
Yes
Yes
Yes
No
No
No
Is the camper subject to?
Frequent colds
Yes
Sinus Trouble
Yes
Kidney Trouble
Yes
Convulsions
Yes
Sleep Walking
Yes
Upset Stomach
Yes
No
No
No
No
No
No
Frequent sore throats
Constipation
Bed Wetting
Ear Trouble
Fainting
Other
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Has the camper had?
Seasonal Allergies Yes
Tuberculosis
Yes
Athletes Foot
Yes
Hernia (Rupture) Yes
Heart Trouble
Yes
ADD/ADHD
Yes
No
No
No
No
No
No
Chicken Pox
Bronchitis
Rheumatic Fever
Diabetes
Asthma
Eating Disorder
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
If you answered yes to any of the above questions, please explain in the space below (an additional sheet may be attached for more room):
Has the camper had any operations or serious injuries? Yes
If yes, please comment:
Are there any restrictions of activity for medical reasons? Yes
If yes, please comment:
No
No
FOOD ALLERGIES
If your child has ANY food allergies, please contact Camp Luther’s Food Service Manager at 715-546-3647 EXT. 228.
Be prepared to share your child’s allergies, needs, dates attending Camp Luther, your concerns, and the best way to ensure the safety of your child.
Are there any additional details or information regarding the camper’s health that either the camp staff or an attending doctor should know?
SPECIAL NEEDS
IF YOUR CHILD HAS ANY PHYSICAL, EMOTIONAL, BEHAVIORAL, OR COGNITIVE SPECIAL NEEDS YOU MUST CONTACT THE YOUTH CAMP
PROGRAM DIRECTOR ASAP TO DISCUSS NECESSARY ARRANGEMENTS! WE WANT TO BE PREPARED TO SERVE YOUR CHILD BEST.
PARENT/GUARDIAN AUTHORIZATION AND OVER-THE-COUNTER MEDICATIONS:
This health history is correct and accurately reflects the health status of the camper to which it pertains. The camper described has permission to
participate in all camp activities except as noted by me on this form. I understand that the information on this form will be shared on a “need-toknow” basis with camp staff. I give permission to photocopy this form. When necessary or beneficial, the camp staff has permission to give the
following medications (or their equivalent) to the camper. Cross out those medications which the camper should not be given.
Acetaminophen (Tylenol)
Generic Cough Drops
Calamine Lotion / Aloe
Ibuprofen (Advil, Motrin)
Sore Throat Spray
Pepto-Bismol / Tums
Phenylephrine decongestant (Sudafed PE)
Benadryl (for allergies)
Antibiotic Cream
The Camp Luther staff will make every attempt to contact you the parent/guardian should the registered camper need medical care. In the event I
cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment,
including hospitalization, for the registered camper. I hereby agree to be responsible for payment of all costs or expenses of any health care
provided or other person who acts in reliance upon this consent and authorization for treatment. In the event of an emergency, I give permission
to the medical personnel selected by the camp director to administer first aid and treatment.
Signature:
Printed Name:
Date:
Relationship to Camper:
12/2015
CAMP LUTHER
CAMPER PROFILE FORM
To be filled out by Parent or Guardian with input from your child
You have sent in your child’s registration form and down payment securing your child’s place at Camp
Luther this summer. Please mark the date on your calendar so you can prepare for the week. In addition
to filling out this form and the medical form, please help prepare your child for camp by talking with
them. Discuss what they can expect in a week at Camp Luther, what kind of behavior you expect them to
display, and how much fun they will have. Discuss the “What to Bring” form with your child. This will
help your child be mentally prepared for the week.
Please complete this form and provide us with any additional information you consider helpful.
Be assured that this information will be held in strict confidence among our staff. The information you
provide will enhance your child’s experience at Camp Luther. We encourage you to keep your child and
our staff in your prayers! It is our prayer that each child at Camp Luther has a positive experience and
grows in their faith development, social skills and appreciation for God’s creation during their week here.
INTERESTS & HOBBIES
Camper’s hobbies:
Camp activities camper is especially looking forward to:
Activities camper is apprehensive about:
Behavior at school is:
 Excellent
 Good
 Fair
 Poor
Camper’s attitude toward school:
Camper Name :_____________________________________________________
Welcome to Camp Luther! Please help us be prepared for your child’s week at camp by completing this
form. The information requested will help the assigned counselor become better acquainted with your
child prior to arrival. This enables us to be more informed and effective in our care of your child and his
or her transition time spent away from home.
Please send this form prior to your camper’s arrival!
For office use only:
This form is now included in our online registration process. If you filled out the
Camper Profile section your online registration, you do not need to fill out this form.
Please do not fax; we will accept scanned & emailed forms to [email protected].
SOCIAL SKILLS & EMOTIONAL HEALTH
Number of Brothers:
Ages:
Number of Sisters:
Ages:
Prior camp experience:
yes no
Significant notes
Do you think camper might become homesick?
Yes
No
Explain:
Block Code:______________________
Describe camper’s reading ability/favorite books:
What care do you recommend for homesickness?
(Calling home is a last resort)
Camper’s temperament is usually: (check all that apply)
 Timid
 Outgoing
 Aggressive
 Sensitive
 Happy
 Moody
 High Strung
 Laid Back
 Nervous
Camper’s fears and weaknesses:
Does your camper know how to swim?  YES
 NO Is Camper afraid of the water?
Describe how camper gets along with other children:
In what way do you think the Camp Luther experience will help your child?
Have there been any significant life changes within the last year that may be affecting your child
emotionally and/or behaviorally? If so, would you be willing to identify them for us?
SPIRITUAL DEVELOPMENT
Home church and denomination
(if applicable):
Has camper been baptized?
Confirmed?
Is camper enrolled in a Parochial School?
Does Camp attend Sunday school?
If yes, where:
Does camper feel comfortable talking about their faith?
How important is faith in the camper’s life?
How can our summer staff assist or encourage your child in their relationship with Jesus?
If they have previously attended Camp Luther (and can remember), who have their counselors been?
NOTE TO THE STAFF
Please include any further information you believe would be beneficial to the Camp Luther Staff.
(REV. 12/2015)
SUMMER CAMP CHECKLIST
PLEASE PLACE CAMPER’S NAME ON ALL BELONGINGS!
CAMP LUTHER IS NOT RESPONSIBLE FOR ITEMS LEFT BEHIND!
SLEEPING GEAR
 Sleeping bag
 Pillow and pillowcase
ITEMS FOR HEALTH AND HYGIENE
 Prescribed medication in original container only
 Body soap
 Shampoo and Conditioner
 Deodorant
 Toothbrush and toothpaste
 Hairbrush or comb
 Towels and wash cloths
 Laundry bag (labeled with name)
OTHER USEFUL ITEMS
 Bible
 Flashlight
 Camera, Batteries, Digital Card
 Beach towel
 Sunscreen and lotion
 Bug Spray
 Paper, pen/pencil, envelopes, Stamps
 Sunglasses
 Hat
 Backpack
 Water Bottle
 Money for Canteen ($20 min. is suggested)
PLEASE LEAVE AT HOME
 Radios
 Televisions
 MP3 Players | iPods
 Knives
 Fireworks
 Skateboards
 Rollerblades
 Pets







Cell Phones!
Laptops
Portable Video Games
Food | Snacks | Drinks
Lighters | matches
Laser Lights
Hair Strengtheners/Curlers
Life jackets are provided for all water
activities, but you may bring a personal
life jacket if you so choose.
CLOTHING
 Changes of jeans, shorts, shirts, underwear, Socks,
etc.
 Tennis shoes
 Light jacket
 Rain gear
 Swimsuit - one piece please! or equivalent to
 Sweatshirt or pullover sweater
 Pajamas
 Sandals
Statement on Dress and Behavior
One of the things that guests to Camp Luther appreciate
most is the family-friendly Christian community that is
created at camp when God’s people gather together. To
maintain this atmosphere we ask that campers, cottagers
and other guests come to Camp Luther with an attitude of
cooperation, goodwill, and a respect for people. We ask
that your language, dress, and behavior while at camp are
appropriate for our Christian community. Thank you for
being considerate of others and helping us to maintain the
special atmosphere we enjoy together at Camp Luther. In
keeping with this policy, we ask that girls wear one piece
bathing suits while at camp. Thank you.
Pathfinder Camp Information
Hello from Camp Luther!
We have received your Pathfinder Camp registration and are eager to share our summer with you!
The following is essential information; please read it carefully.
PROGRAM INFORMATION
Pathfinder is an exciting, five-night residential camp for youth grades 3-6. Campers grow in faith, independence, and interpersonal skills as
they live, eat, and play with their counselors and other campers. In this small-group based camp, counselors lead intentional activities designed to promote friendships and Christian community. Don’t miss out on this experience for your child!
ARRIVAL AND DEPARTURE:
Check-in is on Sunday between 1:30 p.m. and 3:30 p.m. (no early check-ins, please).
If you plan on arriving after 3:30 p.m., please let us know ahead of time so we can make special arrangements
to have someone available to meet you. Camp ends on Friday at 11:00 a.m. You are invited to join us for closing
devotions at 10:30 a.m. Sorry, lunch is not available.
CANCELLATION AND TRANSFER FEE
Your deposit is non-refundable and non-transferable. No refunds are granted within 30 days of your camper session except in cases of illness
or injury (with doctor’s note), and family emergencies. A prorated portion of the registration fee less your deposit will be refunded if a camper
is sent home due to illness or injury. Refunds will not be made for a remaining period of two days or less. If a camper leaves early due to
homesickness, disciplinary reasons, or parent request, no refund will be given. All refunds must be requested in writing. A $10 fee will be
charged for all changes to dates and/or housing once your registration has been finalized.
PHOTOGRAPHS
Camp Luther regularly uses photographs and/or video images of camper participants for official Camp Luther promotional purposes including
print, internet, social media, video, and other media. While your child's image may be captured, their name will not be shared. If you wish for
your child to be excluded, please provide a request in writing along with a photo of your child.
THE CANTEEN AND SPENDING MONEY
Campers visit the Camp Luther Canteen twice a day for snacks and souvenirs. Campers are allowed to purchase three items per session.
Snacks and drinks are $1.00. Clothing and souvenir prices range from $.50- $40.00.
SPECIAL DIETARY NEEDS / FOOD ALLERGIES
If your child has special dietary needs or food allergies, we are willing to work with you to make sure your child is properly fed. Our Food Service Director, Ren, will be happy to provide the planned menu for your time at camp. For questions or concerns she can be contacted at
[email protected]. If your child has special dietary needs please contact our Food Service Director.
FORMS
Parents or guardians are to complete the Camper Profile Form and the Emergency Medical Form on or before June 1st.
These are available within the online registration system or as a part of this information packet.
State law mandates that all prescription medication brought to camp must be in its original container.
PAYMENTS
Full payment is required on or before June 1st. Payment of your balance can be made by check or credit card, via postal mail or submitting a credit card payment at www.campluther.com. If you register after June 1st, payment is due in full.
CAMPER EXPECTATIONS
Camp Luther provides opportunities for spiritual growth, social development, and outdoor activity. We would like to provide a Christian environment for all who visit. We ask that each camper’s behavior, speech and clothing are appropriate for the Christian atmosphere we try to
model. Please mark and label your camper’s property.
PROGRAM INFORMATION
Housing will be provided in our retreat center.
MORE INFORMATION FOR PARENTS
Check out the Questions and Answers page of our website.
Click on the “Summer Camps” tab, then “For Parents”.
12/2015