Summer Camp

All our Summer Camp Sessions are currently full. Please call the Shiloh Camp office at (405) 858-7011 to be added to the waiting list.

Camper Information:

You can also download and print this form.

All fields are required

Camper Name:
	Male  Female
Previous Camper:	Yes  No
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Home Phone:
Age (by Camp):
Grade (this fall):
School Attending (this fall):
Church you most regularly attend:
Birthday:	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 [YYYY]
Ethnicity:
How did you find out about Shiloh?

Please Choose A Session* (One session per child):
	Camper Session 1: June 7th – 11th (ages 12 – 16) - deadline May 10th     *This session is now FULL, please choose another session
	Camper Session 2: June 14th – 18 (ages 8 – 11) - deadline May 17th     *This session is now FULL, please choose another session
	Camper Session 3: June 21st – 25th (ages 8 – 11) - deadline May 24th     *This session is now FULL, please choose another session
	Camper Session 4: July 12th – 16th (ages 8-11) - deadline June 14th     *This session is now FULL, please choose another session
	Camper Session 5: July 19th – 23rd (ages 8-11) - deadline June 21st     *This session is now FULL, please choose another session
	Camper Session 6: July 26th – 30th (ages 12 – 16) - deadline June 28th     *This session is now FULL, please choose another session

*Please note that your child's reservation is not confirmed until payment has been received or payment arrangements have been made. Cost is $20 per child before the deadline. If space is available after the deadline, the cost is $30 per child.

Parent/Guardian Information

Name:
Work Phone:
Pager/Cell Phone:

Emergency Contact Information

1. Name:
Relationship to child:
Home Phone:
Work Phone Phone:
Pager/Cell Phone:
2. Name:
Relationship to child:
Home Phone:
Work Phone Phone:
Pager/Cell Phone:

Authorized Pick-Up List

1. Name
Phone:
2. Name
Phone:
3. Name
Phone:

Medical Information

Can camper fully participate in the active camp program?

Yes

No

If No, please explain:

Does the camper have any of the following conditions? (Check All That Apply)

Asthma  Does camper use an inhaler?  Convulsions  Blood or clotting disorders  Seasonal Allergies  Diabetes  Hyperactivity - ADD or ADHD

Other Behavior problems or medical conditions:

Anything that we should know to help us get to know your child:

Is your child allergic to any medications?

Yes   No Please List:

Is your child allergic to any foods?

Yes   No Please List:

Digital Signature

Information/Medical Release
I hereby grant Shiloh Summer Camp of Oklahoma City, its nominees and agents, unlimited permission to use, publish, and republish for purposes of advertising and trade and for such uses as it may determine, information and reproductions of my child’s likeness (photographic or otherwise), my child’s voice, and my child’s statements related to his/her involvement as a Shiloh camper or related to the assistance he/she has received from Shiloh or any of its partner agencies, with or without identification of the child by name. I understand that my child’s likeness, voice and/or statements could be used in or on, but not be restricted to, pamphlets, posters, booklets, brochures, radio or television advertising, promotional videos, and other forms of printed, video, or audio material. I, as the child’s parent or guardian, waive any right to prior approval for use of any likeness of the child, their voice, or statements associated with the matters covered by this release. I further waive any claim for compensation of any kind or nature for the use of any likeness of the child in my care, their voice, or statements associated with the matters covered by this release.

I hereby grant Shiloh Summer Camp of Oklahoma City, its nominees and agents unlimited permission to release my child’s contact information (being address and phone number) with the purpose of recommending the child to a mentor or after-school program. For the year June 1, 2010 through May 31, 2011, I do hereby release, forever discharge and agree to hold harmless Shiloh Summer Camp Inc. and Eagle Ridge Institute (hereinafter “Shiloh” and “ERI”) and any and all directors thereof from any and all liability, claims or demands and expenses of any nature whatsoever which may be incurred by the undersigned participant that occur while participating in any Shiloh/ERI activity or workday, so long as prudent and reasonable care has been maintained and Shiloh/ERI is not solely negligent. I do hereby grant permission of Shiloh/ERI directors or staff to take said participant to a physician or hospital, and hereby authorize medical treatment including but not in limitation to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical services rendered under this authorization.

By typing your name below (name of the Parent/Guardian), you are affirming that you are indeed the Parent/Guardian and the information you have provided is true; you are also agreeing to the terms of the "Information/Medical Release" as mentioned above: