Lake Ellen Camp

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Please register below for Chill Out - February 15-17, 2019 -  Grades 6th-12th. If you have questions please contact us at 906-542-3529 or office@lakeellencamp.org.
* Denotes a required field to fill in
Where did you hear about Lake Ellen?*
Facebook
Radio
Poster
Brochure
Church
Internet
Friend
Other Social Media
Other
Camper's First Name*
Camper's Last Name*
Address*
City*
State*
Zip*
Phone (including area code)*
Emergency Contact Name*
Emergency Contact Phone*
Email*
Verify Email*
Church
Gender*
Male
Female
Birthday (MM/DD/YY)*
Grade*
Father's Name & Occupation*
Mother's Name & Occupation*
I would like to room with: (LIMIT 2)

HEALTH FORM


Camper's FULL name*
Name of Physician*
Physican Phone*
Insurance Company*
Policy Number*
Allergies
Precautions to be observed
Known Communicable Diseases
Prescription Medications (Must be brought in original containers)
Non-Prescription Medications
Special Housing/Disability Needs
Are Immunizations up to date?*
YES
NO
Date of last Tetanus Booster (MM/DD/YYYY)
Known Diseases or Conditions
Asthma
Diabetes
Bowel Habits
Colds
Heart
Epilepsy
Nose Bleeds
Menstrual Problems
Headaches
Sore Throats
Bed Wetting
Sleepwalking
Dizziness Fainting
Special Dietarty Needs
Additional Comments?

Waiver Acceptance Required
Please read and sign the below waiver.


Acceptance:* 
Full Name:*